rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
11332,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2010-12-28,152,D,,,OYFI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to verify that a surrogate decision-maker had the necessary authority to act on behalf of a resident who had been determined to lack the capacity to make healthcare decisions, for one (1) of six (6) sampled residents. Resident identifier: #23. Facility census: 89. Findings include: a) Resident #23 A review of Resident #23's medical record revealed a [AGE] year old female who was originally admitted to the facility on [DATE], and who had been determined to lack the capacity to make healthcare decisions by her attending physician on 08/21/08. The face sheet in the resident's record indicated the resident had designated an individual to serve as her medical power of attorney representative (MPOA), but there was no copy of this document in the record. Social service notes, dated 12/13/10, stated the resident's sister had been appointed to serve as her health care surrogate (HCS), and documentation elsewhere in the record indicated this HCS was making healthcare decisions for the resident. No record of the appointment of a HCS by the resident's attending physician was located in the record. During an interview with the social worker (Employee #5) at 10:40 a.m. on 12/28/10, she verified, after review of the resident's medical record and her office records, that there was no record of a legal representative. She speculated it had been misplaced at some point. .",2014-04-01
11333,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2010-12-28,225,D,,,OYFI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and family interview, the facility failed to report allegations involving mistreatment and/or neglect to the appropriate agencies in accordance with State law for three (3) of six (6) sampled residents. Resident identifiers: #37, #38, and #67. Facility census: 89. Findings include: a) Resident #37 A review of the medical record revealed Resident #37 was an [AGE] year old male who has been determined to lack the capacity to form healthcare decisions, and his minimum data set and care plan indicated he was totally dependent upon staff for hygiene. A review of a grievance form revealed that, on 11/16/10, the resident's wife / healthcare surrogate (HCS) reported to a nurse (Employee #7) that the resident's nails were dirty at times and that she always had to cut his nails herself. The nurses' notes indicated this allegation of neglect was investigated and being followed up by Employee #7 and a nursing assistant and, when checked on 11/17/10, his nails were clean. Daily monitoring of the resident's nails was ordered by the physician and added to the care plan. But this allegation of neglect was not reported to the Ombudsman, Adult Protective Services, or to State survey and certification agency as required by state law and the facility's policy. -- b) Resident #38 A review of the clinical record for Resident #38 revealed an [AGE] year old male with [DIAGNOSES REDACTED]. He had been determined by the attending physician to lack the capacity to form healthcare decisions, and his niece was his medical power of attorney representative (MPOA). A grievance form was filed on 11/08/10, after the facility received a letter from the MPOA stating she had spoken to a staff member two (2) weeks prior and complained that the resident had become unable to physically lift his arm enough to feed himself, but nothing had been done and he was still having his tray set up and being left to feed himself. During an interview with the MPOA at 12:50 p.m. on 12/28/10, she verified she had told three (3) different employees about the fact that the resident could no longer feed himself or get a drink of water on his own. The MPOA stated the resident's mouth was very dry and the nurse had told her that he was losing weight. Her only answer from nursing was, ""We'll write it in the notes."" She stated she had asked an aide to feed him but was told they needed to get an ""okay"" from the nurse. She stated that, after she wrote the letter, the facility took action, had tests done, and instructed the staff to feed him. The original assessment by the registered dietitian (RD), on 06/20/10, noted his weight as 204.2 pounds and his intake at 92%. A dietary entry on 12/16/10 noted, ""MPOA aware of Monthly weight trigger; Resident has had a 9.54% wt. loss x 1 month, 10.15% wt. loss x 3 months and 14.68% wt. loss x 6 months."" An investigation took place as evidenced by an immediate speech therapy evaluation; a referral to the Veteran's Hospital for an evaluation of his decline; and, on 11/10/10, he was changed to having meals in the restorative dining room. But this allegation of neglect was not reported to the Ombudsman, Adult Protective Services, or to State survey and certification agency as required by state law and the facility's policy. -- c) Resident #67 A review of the grievance reports revealed that, on 11/15/10, Resident #67 (who had been determined by the attending physician to have the capacity to form her own healthcare decisions on 10/10/10) reported allegations that she was not getting the care she needed. She stated to Employee #8 (the admissions person) that: (1) she could not reach her call bell; (2) she hadn't been gotten out of bed for two (2) days, and (3) one (1) of the aides (Employee #9) had been rude to her when she asked to get up and told her she would have to wait and that he didn't have to do what she said. Employee #8 recorded the allegations and began an investigation, and counseling was done with the staff, but these allegations of neglect were not reported to the Ombudsman, Adult Protective Services, or to State survey and certification agency as required by state law and the facility's policy. During the investigation, Employee #10 gave a signed statement the resident had also reported to her on 11/12/10, that her light was not being answered. -- d) During an interview with the administrator, the acting director of nursing, and the social worker at 1:45 p.m. on 12/28/10, this surveyor stated to them that the above grievances contained allegations of mistreatment and/or neglect and, as such, should have been immediately reported to the appropriate State officials prior to the initiating of investigations. The outcome of the investigations should also have been reported. The three (3) of them reviewed the grievances and did not offer any alternative explanations but stated that they would file reports as soon as possible. .",2014-04-01
11334,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2010-12-28,323,D,,,OYFI11,"**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 one (1) of six (6) sampled residents was free from accident hazards over which the facility had control, and the facility failed to provide adequate supervision and/or assistive devices by failing to put preventive interventions into place after an identified accident. Resident identifier: #23. Facility census: 89. Findings include: a) Resident #23 A review of the medical record revealed Resident #23 was a [AGE] year old female, who was alert and oriented, but whose sister who had been appointed to serve as her health care surrogate (HCS) per the social worker, to assist her with healthcare decisions. A facility investigation report indicated that, on 12/15/10, the resident was found with her right foot caught in the siderail of her bed in her bedroom resulting in redness of the entrapped area. The resident had a physician's orders [REDACTED]. A Side Rail Evaluation Screen was completed on 12/27/10, and the decision was made to add padded coverings to the siderails. The assessment nurse (Employee #6) presented a copy of the care plan at 2:00 p.m. on 12/28/10, with an added intervention (hand-written) dated 11/22/10 which read: ""Bilateral 1/2 SR padded for T & R (turning and repositioning)."" An observation of the resident was made at 10:45 a.m. on 12/27/10, while she was lying in bed in her room. Both 1/2 siderails were raised and appeared to have a satisfactory fit to the bed, but there was no padding on the rails. In an interview with the resident at that time, she stated she did like having the rails to use when she moved about in bed. She remembered getting her foot caught in the rail and said she was being careful not to do it again. During a staff interview with the interim director of nurses at 11:15 a.m. on 12/28/10, she acknowledged the padding had not been added until the evening of 12/27/10, when she realized that her instructions to the nursing staff to pad the rails ""on Friday"" had not been carried out. .",2014-04-01
11335,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2010-12-28,514,D,,,OYFI11,"**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 medical record by continuing to indicate, in the physician's progress notes, that two (2) of six (6) sampled residents were on medications and/or dosages that had been changed and/or discontinued. Resident identifiers:#37 and #87. Facility census: 89. Findings include: a) Resident #37 A review of the medical record found Resident #37 presently had physician's orders [REDACTED].@ bedtime"" (with a start date of 09/13/10) and ""[MEDICATION NAME] (insulin [MEDICATION NAME]) 100 unit/ml solution subcutaneous - once daily Everyday: 4 units"" (with a start date of 07/07/10). A review of the physician's progress notes revealed the physician's assistant (Employee #4) had documented on all entries back to 06/15/10 that the resident was receiving the following drug therapy for treatment of [REDACTED]. DM II (diabetes mellitus type II): [MEDICATION NAME] 20U qhs (each night). Presently taking [MEDICATION NAME] 2U with supper and continue 4U with breakfast and lunch. Will continue to monitor qid (four-times-a-day)."" During an interview with Employee #4 at 11:50 a.m. on 12/28/10, he acknowledged, after checking the orders, that the notes were inaccurate, but he commented ""the nurses know not to go by (his) notes."" The medical director, who was present at exit, stated that corrections would be made. -- b) Resident #87 A review of the physician's progress notes written by the physician's assistant (Employee #4), on 12/09/10, 10/19/10, 09/21/10, and 08/24/10, all stated Resident #87 was being treated with the following: ""1. [MEDICAL CONDITION]'s chorea: Klonopin 1 mg bid (twice daily). [MEDICATION NAME] mg qhs for [MEDICAL CONDITION]. [MEDICATION NAME] 7.5 mg 1 po (by mouth) qhs."" A review of the record found the [MEDICATION NAME] was discontinued on 07/22/10 and [MEDICATION NAME] discontinued in August 2009. During an interview with Employee #4 at 11:50 a.m. on 12/28/10, he acknowledged, after checking the orders, that the notes were inaccurate, but he commented ""the nurses know not to go by (his) notes."" The medical director, who was present at exit, stated that corrections would be made.",2014-04-01
11336,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2011-01-11,318,E,,,CVPG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interviews, the facility failed to provide a continuity of restorative nursing services as ordered by the physician to maintain and/or increase strength and/or range of motion (ROM). Thirty-six (36) residents had physician orders [REDACTED]. Resident identifiers: #1, #2, #5, #7, #8, #10, #11, #12, #14, #15, #17, #18, #23, #24, #25, #32, #33, #35, #42, #43, #44, #48, #50, #53, #57, #60, #61, #62, #63, #64, #67, #68, #70, #73, #76, and #77. Facility census: 76. Findings include: a) Residents #1, #2, #5, #7, #8, #10, #11, #12, #14, #15, #17, #18, #23, #24, #25, #32, #33, #35, #42, #43, #44, #48, #50, #53, #57, #60, #61, #62, #63, #64, #67, #68, #70, #73, #76, and #77 On 01/10/11, a review of the facility's ""Restorative Nursing and Progress Summary"" for the months of January 2011 and December 2010 was completed to determine whether residents were receiving restorative nursing services at the frequency ordered by their attending physician Month-to-date in January 2011, twenty-four (24) residents did not receive restorative nursing services for active / passive ROM, therapeutic / strengthening exercises, and/or the application of splints on five (5) of ten (10) days. These were Residents #2, #5, #7, #8, #10, #12, #15, #24, #25, #33, #35, #42, #43, #44, #50, #57, #60, #61, #63, #64, #67, #68, #73, and #76. During the month of December 2010, thirty-six (36) residents did not receive restorative nursing services for active / passive ROM, therapeutic / strengthening exercises, and/or the application of splints on anywhere between three (3) and eight (8) days of this month. These were Residents #1, #2, #5, #7, #8, #10, #11, #12, #14, #15, #17, #18, #23, #24, #25, #32, #33, #35, #42, #43, #44, #48, #50, #53, #57, #60, #61, #62, #63, #64, #67, #68, #70, #73, #76, and #77. Each resident had one (1) or more physician orders [REDACTED]. Restorative nursing services were ordered for seven (7) days a week with two (2) restorative aides providing the restorative services. A licensed practical nurse (LPN) was currently in charge of the program, and a registered professional nurse (RN) had been hired to assume the supervision of the restorative nursing program. An interview with a restorative aide (Employee #60), on 01/10/11 at 10:30 a.m., revealed the restorative aide was assigned to drive the facility van to take residents to appointments. On this date of 01/10/11, she was scheduled to leave the facility to transport residents to four (4) appointments. She stated, ""I am a van driver."" An interview with another restorative aide (Employee #63), on 01/11/11 at 11:30 a.m., revealed that any areas on the facility's ""Restorative Nursing and Progress Summary"" marked with an ""X"" indicated that the restorative services was not provided for the resident. She reported the restorative aides were pulled to the floor for direct care services when there were call-offs, and this occurred frequently. When they were pulled to the floor to provide direct care for the residents, the restorative services were not provided for those residents requiring the services. An interview with the administrator, on 01/11/10 at 1:00 p.m., revealed they had made changes to the restorative nursing program to address the issue of residents not receiving services when the restorative aides were pulled to drive the van or work on the floor.",2014-04-01
11337,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2011-01-11,311,E,,,CVPG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interviews, the facility failed to provide a continuity of restorative nursing services as ordered by the physician to maintain and/or increase self-performance of transfer / ambulation and/or eating activities. Twenty-four (24) residents had physician orders [REDACTED]. Resident identifiers: #2, #5, #7, #11, #12, #15, #17, #18, #21, #23, #24, #33, #41, #48, #52, #53, #57, #61, #62, #68, #70, #74, #76, and #77. Facility census: 76. Findings include: a) Residents #2, #5, #7, #11, #12, #15, #17, #18, #21, #23, #24, #33, #41, #48, #52, #53, #57, #61, #62, #68, #70, #74, #76, and #77 On 01/10/11, a review of the facility's ""Restorative Nursing and Progress Summary"" for the months of January 2011 and December 2010 was completed to determine whether residents were receiving restorative nursing services at the frequency ordered by their attending physician Month-to-date in January 2011, fourteen (14) residents did not receive restorative nursing services for transfer / ambulation or activities to improve eating on five (5) of ten (10) days. These were Residents #2, #5, #7, #12, #15, #24, #33, #41, #52, #57, #61, #68, #74, and #76. During the month of December 2010, thirty-six (36) residents did not receive restorative nursing services for transfer / ambulation or activities to improve eating on anywhere between three (3) and eight (8) days of this month. These were Residents #2, #5, #7, #11, #12, #15, #17, #18, #21, #23, #24, #33, #41, #48, #52, #53, #57, #61, #62, #68, #70, #74, #76, and #77. Each resident had a physician orders [REDACTED]. Restorative nursing services were ordered for seven (7) days a week with two (2) restorative aides providing the restorative services. A licensed practical nurse (LPN) was currently in charge of the program, and a registered professional nurse (RN) had been hired to assume the supervision of the restorative nursing program. An interview with a restorative aide (Employee #60), on 01/10/11 at 10:30 a.m., revealed the restorative aide was assigned to drive the facility van to take residents to appointments. On this date of 01/10/11, she was scheduled to leave the facility to transport residents to four (4) appointments. She further stated, ""I am a van driver."" An interview with another restorative aide (Employee #63), on 01/11/11 at 11:30 a.m., revealed that any areas on the facility's ""Restorative Nursing and Progress Summary"" marked with an ""X"" indicated that the restorative services was not provided for the resident. She further stated that the restorative aides were pulled to the floor for direct care services when there were call-offs, and this occurred frequently. When they were pulled to the floor to provide direct care for the residents, the restorative services were not provided for those residents requiring the services. An interview with the administrator, on 01/11/10 at 1:00 p.m., revealed they had made changes to the restorative nursing program to address the issue of residents not receiving services when the restorative aides were pulled to drive the van or work on the floor. .",2014-04-01
11338,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2010-12-09,225,D,,,9K0R11,". Based on review of abuse / neglect policies, review of employees' personnel files, and staff interview, the facility failed make reasonable efforts to uncover information about any past criminal prosecutions to assure that individuals are not employed who have been potentially found guilty of abusing, neglecting, or mistreating residents by a court of law for one (1) of seven (7) employee personnel records reviewed. Facility census: 115. Findings include: a) The facility was entered at 12:15 p.m. on 12/09/10, to conduct an unannounced complaint investigation alleging that the facility did not perform necessary screening for potential employees to rule out criminal convictions that would make them unfit for service in a nursing facility. Review of the facility's policy addressing the prevention of resident abuse / neglect ""1.0-WV Abuse Prohibition"" (revised 11/01/09) found the following under the section entitled ""Process"": ""2. The Center will screen potential employees for a history of abuse, neglect, or mistreating residents... ""2.1.2.1 Knowledge of actions by a court of law against an employee, which would indicate unfitness for service..."". Review of the personnel file for nursing assistant (NA) #1 found she had previously worked in the Commonwealth of Virginia. The personnel file contained no evidence to reflect the facility made a reasonable effort to determine whether this individual had criminal convictions in Virginia which would render him / her unfit to work in a long term care facility. An interview with the administrator, on 12/09/10 at 3:10 p.m., confirmed the facility had no evidence that NA #1 had been screened for criminal convictions in Virginia.",2014-04-01
11339,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2010-12-09,157,D,,,U1IJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to notify a resident's legal representative when they commenced a new form of treatment. One (1) of six (6) sampled residents was initiated into the fine dining program and the walk-to-dine program (during which residents are transferred from their wheelchairs into regular chairs without the use of mobility alarms or seat belts), with no evidence of family notification of this change in treatment or what it involved. The resident, who was seated in a regular chair at a table in the dining room without safety devices, got up from the chair by herself and fell to the floor, sustaining significant injury. The family of the resident was not informed that the use of these safety devices would not be permitted during fine dining and/or the walk-to-dine program. Resident identifier: #111. Facility census: 110. Findings include: a) Resident #111 1. Closed record review revealed Resident #111 was walked to the dining room by a staff member on [DATE] and assisted to sit in a chair at the dining room table with no alarms or seat belts in place; she then arose from the chair without assistance and sustained a fall with significant injuries. Subsequently, she was sent to the hospital per ambulance, was diagnosed with [REDACTED]. She expired on [DATE]. -- 2. Record review revealed physician's orders [REDACTED]. Review of the November physician's orders [REDACTED]. The was also revealed no evidence of orders for gradual reduction of restraint alternative or for permission for the resident to sit up in the chair without either a self-release Velcro seat belt or chair alarm. -- 3. Review of the resident's care plan effective in [DATE] revealed a problem of having a history of falls, decreased mobility and cognitive impairment. Interventions included: ""Monitor Tab alarm is secured to back of bed when resident is in bed and secured to back of chair when resident is oob (out of bed) to chair. ... ""Monitor resident to have self-release seat belt with alarm on when oob to w/c (wheel chair)."" Review of the care plan revealed no evidence of plans to walk the resident to the dining room for the fine dining or walk-to-dine program, for gradual reduction of restraint alternatives, or for the resident to be up in a dining room chair without a chair alarm or seat belt. -- 4. During an interview on [DATE] at 9:30 a.m., a restorative nursing assistant (Employee #69) said that she and other staff were told that residents who are walked to the dining room were to be seated and pushed up close to the table, that the big dining room chairs with armrests were too heavy for residents to scoot, and residents wouldn't need alarms and seat belts while in those heavy chairs, as there was always staff in the dining room. She said the facility's plan was for residents to be ambulated to the dining room if they are able, and those who could not ambulate were to be brought to the dining room in wheelchairs. She said Resident #111 had no alarms, wheelchair, or safety belt in place in the dining room on [DATE], and she was sitting in a regular dining room chair prior to the fall. -- 5. Interviews with two (2) nursing assistants (Employees #4 and #56), a restorative nursing assistant (Employee #49), and a registered nurse (Employee #27), on [DATE] and [DATE], revealed they were told that residents in the restorative program are to be walked and assisted to sit in the dining room chair without alarms. However, residents who were wheeled to the dining room were allowed to have tab alarms or safety belts if they used them. -- 6. Interview, on [DATE] at 1:30 p.m., with the director of nursing (DON - Employee #104) revealed Resident #111 had an order for [REDACTED]. The DON explained that, sometime in September or [DATE], the corporate office encouraged the facility to have a fine dining program and a walk-to-dine program, and they were moving slowly into those programs. When asked if there were a policy or procedure regarding safety needs of residents who attended fine dining (such as not allowing alarms or seat belts if they walk to the dining room), she said they were in the process of writing procedures and she would try to look and see if there were any policies regarding safety issues in fine dining. When asked, she said she could not speak to whether Resident #111's legal representative was made aware of her transition to fine dining and that alarms or seat belts would not be used while dining. -- 7. Record review of nursing notes, from [DATE] until her death on [DATE], found no evidence of communication to the family related to Resident #111 participating in the fine dining or walk-to-dine program. In an interview on [DATE] at 1:45, the social workers (Employees #96 and #108) revealed they did not know whether Resident #111's power of attorney knew, before the resident's fall in the dining room on [DATE], that the resident's tab alarm and safety belt were not being used because of the change to fine dining. Employee #108 stated that, if a letter were sent out to everyone about a resident's transition to fine dining, then everyone would be assured of having been notified, but no letter was sent to families to her knowledge. They said they believed that seat belts were not allowed while residents were seated in regular chairs during fine dining as that would not be dignified. .",2014-04-01
11340,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2010-12-09,280,D,,,U1IJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to revise a care plan for one (1) of six (6) sampled residents when she was initiated into the facility's newly established walk-to-dine and fine dining programs, during which residents are transferred from their wheelchairs into regular chairs without the use of mobility alarms or seat belts. Resident #111, who had an order for [REDACTED]. needs while in the walk-to-dine / fine dining program. Resident identifier: #111. Facility census: 110. Findingd include: a) Resident #111 1. Closed record review revealed Resident #111 was walked to the dining room by a staff member on [DATE] and assisted to sit in a chair at the dining room table with no alarms or seat belts in place; she then arose from the chair without assistance and sustained a fall with significant injuries. Subsequently, she was sent to the hospital per ambulance, was diagnosed with [REDACTED]. She expired on [DATE]. -- 2. Record review revealed physician's orders [REDACTED]. Review of the November physician's orders [REDACTED]. There was also no evidence of orders for gradual reduction of restraint alternative or for permission for the resident to sit up in the chair without either a self-release Velcro seat belt or chair alarm. -- 3. During an interview on [DATE] at 9:30 a.m., a restorative nursing assistant (Employee #69) said that she and other staff were told that residents who are walked to the dining room were to be seated and pushed up close to the table, that the big dining room chairs with armrests were too heavy for residents to scoot, and residents wouldn't need alarms and seat belts while in those heavy chairs, as there was always staff in the dining room. She said the facility's plan was for residents to be ambulated to the dining room if they are able, and those who could not ambulate were to be brought to the dining room in wheelchairs. She said Resident #111 had no alarms, wheelchair, or safety belt in place in the dining room on [DATE], and she was sitting in a regular dining room chair prior to the fall. -- 4. Interview, on [DATE] at 1:30 p.m., with the director of nursing (DON - Employee #104) revealed Resident #111 had an order for [REDACTED]. The DON explained that, sometime in September or [DATE], the corporate office encouraged the facility to have a fine dining program and a walk-to-dine program, and they were moving slowly into those programs. When asked if there were a policy or procedure regarding safety needs of residents who attended fine dining (such as not allowing alarms or seat belts if they walk to the dining room), she said they were in the process of writing procedures and she would try to look and see if there were any policies regarding safety issues in fine dining. When asked, she said she could not speak to whether Resident #111's legal representative was made aware of her transition to fine dining and that alarms or seat belts would not be used while dining. -- 5. Review of the resident's care plan effective in [DATE] revealed a problem of having a history of falls, decreased mobility and cognitive impairment. Interventions included: ""Monitor Tab alarm is secured to back of bed when resident is in bed and secured to back of chair when resident is oob (out of bed) to chair. ... ""Monitor resident to have self-release seat belt with alarm on when oob to w/c (wheel chair)."" Review of the care plan revealed no evidence of plans to walk the resident to the dining room for the fine dining or walk-to-dine program, for gradual reduction of restraint alternatives, or for the resident to be up in a dining room chair without a chair alarm or seat belt. .",2014-04-01
11341,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2010-12-09,323,G,,,U1IJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to develop and implement written policies and procedures to ensure that residents receive care and services necessary to prevent avoidable accidents This was evident for one (1) of six (6) sampled residents whose treatment was changed without a physician's orders [REDACTED]. There was no evidence this resident (who had been identified as being at risk for falls) was first assessed to see if she was a candidate for removal of safety devices while in the dining program and no evidence of care planning for safety interventions to prevent accidents while participating in these programs. Additionally, there were no written guidelines or interventions for staff to follow to assure the resident's safety needs were met. Resident identifier: #111. Facility census: 110. Findings include: a) Resident #111 1. Closed record review revealed Resident #111 was walked to the dining room by a staff member on [DATE] and assisted to sit in a chair at the dining room table with no alarms or seat belts in place; she then arose from the chair without assistance and sustained a fall with significant injuries. Subsequently, she was sent to the hospital per ambulance, was diagnosed with [REDACTED]. She expired on [DATE]. -- 2. Record review revealed physician's orders [REDACTED]. Review of the November physician's orders [REDACTED]. Review of the November physician's orders [REDACTED]. -- 3. Review of the resident's care plan effective in [DATE] revealed a problem of having a history of falls, decreased mobility and cognitive impairment. Interventions included: ""Monitor Tab alarm is secured to back of bed when resident is in bed and secured to back of chair when resident is oob (out of bed) to chair. ... ""Monitor resident to have self-release seat belt with alarm on when oob to w/c (wheel chair)."" Review of the care plan revealed no evidence of plans to walk the resident to the dining room for the fine dining or walk-to-dine program, for gradual reduction of restraint alternatives, or for the resident to be up in a dining room chair without a chair alarm or seat belt. -- 4. During an interview on [DATE] at 9:30 a.m., a restorative nursing assistant (Employee #69) said that she and other staff were told that residents who are walked to the dining room were to be seated and pushed up close to the table, that the big dining room chairs with armrests were too heavy for residents to scoot, and residents wouldn't need alarms and seat belts while in those heavy chairs, as there was always staff in the dining room. She said the facility's plan was for residents to be ambulated to the dining room if they are able, and those who could not ambulate were to be brought to the dining room in wheelchairs. She said Resident #111 had no alarms, wheelchair, or safety belt in place in the dining room on [DATE], and she was sitting in a regular dining room chair prior to the fall. -- 5. Interviews with two (2) nursing assistants (Employees #4 and #56), a restorative nursing assistant (Employee #49), and a registered nurse (Employee #27), on [DATE] and [DATE], revealed they were told that residents in the restorative program are to be walked and assisted to sit in the dining room chair without alarms. However, residents who were wheeled to the dining room were allowed to have tab alarms or safety belts if they used them. -- 6. Interview, on [DATE] at 1:30 p.m., with the director of nursing (DON - Employee #104) revealed Resident #111 had an order for [REDACTED]. The DON agreed that Resident #111 was not using a tab alarm, self-releasing seat belt, or wheelchair at the time of the fall in the dining room on [DATE]. The DON explained that, sometime in September or [DATE], the corporate office encouraged the facility to have a fine dining program and a walk-to-dine program, and they were moving slowly into those programs. When asked if there were a policy or procedure regarding safety needs of residents who attended fine dining (such as not allowing alarms or seat belts if they walk to the dining room), she said they were in the process of writing procedures and she would try to look and see if there were any policies regarding safety issues in fine dining. When asked, she said she could not speak to whether Resident #111's legal representative was made aware of her transition to fine dining and that alarms or seat belts would not be used while dining. -- 7. In an interview on [DATE] at 1:45, the social workers (Employees #96 and #108) revealed they did not know whether Resident #111's power of attorney knew, before the resident's fall in the dining room on [DATE], that the resident's tab alarm and safety belt were not being used because of the change to fine dining. Employee #108 stated that, if a letter were sent out to everyone about a resident's transition to fine dining, then everyone would be assured of having been notified, but no letter was sent to families to her knowledge. They said they believed that seat belts were not allowed while residents were seated in regular chairs during fine dining as that would not be dignified. -- 8. During an interview with a member of the activities staff (Employee #35) on [DATE] at 3:20 p.m., she said she was the only staff member in the dining room on [DATE] at the time Resident #111 fell , although she was not assigned to be in the dining room that day at any certain time. She said she went to the kitchen on her own initiative on [DATE], to check if any of the trays were ready or if the dietary staff needed her to start pouring drinks. When asked, she said the noon meal was typically served at 12:10 p.m. in the dining room. She stated that, at 11:45 a.m. on [DATE], she looked up and saw Resident #111 walking and hurried to her, but she could not reach the resident before she fell . She said the resident had no alarm or safety belt in place and she was sitting at the table by herself. -- 9. When asked, during an interview on [DATE] at 4:00 p.m., why Resident #111 was in the dining room so early before the meal, the DON said Resident #111 was one of the easiest residents to walk, so she would have been one of the first brought down to the dining room. She said there was no written safety policy or procedure regarding the use of alarms or seat belts that she could find related to fine dining. Resident #111 had an order for [REDACTED]. .",2014-04-01
11342,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-12-09,155,D,,,OEY611,"**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 seven (7) sampled residents (who had the capacity to understand and make a health care decision) was fully informed in advance of the nature of a surgical procedure (incision and drainage of a large hematoma); understood the possible consequences of the procedure; and was asked for a written consent prior to the undertaking of the procedure. This invasive procedure resulted in harm to the resident, who experienced increased pain, anxiety, and bleeding, which necessitated a transfer to the hospital emergency room for additional procedures. Resident identifier: #118. Facility census: 117. Findings include: a) Resident #118 1. A review of Resident #118's closed medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE], and her [DIAGNOSES REDACTED].#), history of venous [MEDICAL CONDITION] (blood clots) and embolism (a mass, such as a detached blood clot, that travels through the bloodstream and becomes lodged in a vessel, obstructing blood flow), [MEDICAL CONDITION], embolism and [MEDICAL CONDITION] of unspecified artery, [MEDICAL CONDITION], and coronary [MEDICAL CONDITION] unspecified type vessel native graft. This resident had been determined by her attending physician to have the capacity to understand and make informed healthcare decisions, and she was described in her nursing notes daily as being alert / oriented and able to make her needs known. In an interview with the social worker (Employee #3) at 3:15 p.m. on 12/08/10, she verified Resident #118 had capacity, although she stated Resident #118's son / MPOA was involved in the resident's care, usually assisted her in decision making, received notices of the care plan conferences, and was notified of changes in her care and health status. This was reflected in her medical record by his signature on various consent forms (e.g., flu vaccine, etc.), her readmission papers after hospitalization , bedhold notices, and notations in nursing notes showing him being notified about changes in her status and/or treatment. -- 2. A review of the medical record found that, at 3:00 p.m. on 12/03/10, the CNP performed an incision and drainage (I&D) on Resident #118's hematoma while at the facility, with two (2) incisions being made. There was no evidence in the medical record that the attending physician had been notified of either the initial assessment of a large hematoma on the resident's lower leg on 12/02/10, or of the decision to proceed with the I&D on 12/03/10, even though the resident had been on long-term [MEDICATION NAME] therapy, had a [DIAGNOSES REDACTED]. - A progress note, dated 12/02/10 and electronically signed by the CNP at 5:34 p.m. on 12/03/10, stated under the heading ""Physical Exam"", ""... general appearance, obese and alert oriented x 3 female in mild amount of distress due to pain left leg-inner aspect. ..."" Under the heading ""Plan"", the CNP recorded, ""A return visit is indicated in 1 day. Resident is stable - hematoma not enlarging at present. ? (unknown) etiology but appears no significant trauma. Most likely due to capillary fragility and [MEDICATION NAME] (sic) tx (treatment). No severe pain. Will elevate and Ice (sic) area and fu (follow-up) (sic) 24 hours and will treat conservatively."" - A subsequent progress note, dated 12/03/10 and electronically signed by the CNP at 5:40 p.m. on 12/03/10, stated under the heading ""Chief Complaint"", ""FU (follow-up) hematoma left leg. Resident evaluated yesterday for hematoma (etiology unknown) - reevaluated today. Resident was complaining of increased pain, hematoma had doubled in size, and skin was cold to touch. INR 2.1. Stated had increased pain if moved leg or pressure applied."" Under the heading ""ROS"" (review of systems) was recorded, ""I reviewed the medical, surgical, family, social, medication, food allergy and patient code status histories. ..."" Under the heading ""Physical Exam"" was recorded, ""... general appearance, obese and alert oriented x 3-very pleasant female in distress due to pain left lower leg. ... Large hematoma which has at least doubled in size since initial evaluation yesterday. Skin is extremely taunt (sic) and area is exquisitely tender to palpation. Area measures 5 cmx4cm (sic) and is circumfrential (sic). ..."" Under the heading ""Services Performed"", the CNP recorded, ""Resident is stable but (sic) am concerned about swelling, pain and coolness of skin over hematoma. (15:00) (3:00 p.m.) Residents (sic) vs (vital signs) stable - INR 2.0 (done this am). Due to fact resident may be developing [DIAGNOSES REDACTED], I attempt (sic) to aspirate hematoma. I clean (sic) hematoma with [MEDICATION NAME] (sic) and attempt to make small incision to drain collected blood. I am (sic) successful in draining about 30 cc's but area is still very large and painful. A small incision is made (sic) posterior aspect of hematoma and (sic) am able to evaluate large amount of formed clots from hematoma. ... area is packed ... Sterile dressing was applied with mild amount of pressure. Hemostasis is obtained and resident states (sic) has complete pain relief. ... 16:45 (4:45 p.m.) call (sic) son (name) and discuss (sic) treatment - he agrees to evacuation of hematoma and packing area. Also agrees with dose of antibiotic. Resident is reevaluated at 17:00 (5:00 p.m.) - No bleeding from area. ... Due to fact resident has multiple comorbidities and is on [MEDICATION NAME] (sic), it is determined by Dr. (name) and myself, (sic) that resident would be better evaluated if was at hospital. Son was notified and I discussed this with resident, who agrees to go ... Will be transferred by EMS (emergency medical services)."" -- 3. A nursing note entered by a licensed practical nurse (LPN - Employee #6) at 3:00 p.m. on 12/03/10 stated, ""... NP requested the pain med during I&D of hematoma to L (left) extremity. I administered pain (med) and left room while procedure was taking place. (After) procedure pt's (patient's) leg kept elevated with dressing in place. Pedal pulse checks (+)."" Subsequent nursing notes on 12/03/10 stated: - At 6:15 p.m., Employee #6 wrote, ""Verbal consent to evacuate hematoma to LLE (left lower extremity) by (name) MPOA ..."" - At 6:30 p.m., Employee #8 (another LPN) wrote, ""VSS (vital signs stable) - 131/55, HR 74, R - 18, Temp 97.2. Resident exhibited an episode of vomiting - reports (symbol for 'no') nausea at this time. Pedal pulses present and easy palpable. (Symbol for 'no') c/o (complaint of) pain, (symbol for 'no') numbness or tingling in L lower extremity. Exhibits ability to move all toes on L foot. L leg remains elevated with application of ice as ordered, (symbol for 'no') [MEDICAL CONDITION] noted, (symbol for 'no') redness, (symbol for 'no') bleeding. Small amount of serosanguiness (sic) (serosanguineous drainage) noted on external bandage / ice pack. Nurse Practitionor (sic) was aware of PT/INR lab drawn 12/2/10 - (Symbol for 'no') N/O (new orders) at this time - MPOA aware of information - Call light in reach of resident, in bed resting."" Employee #6 also wrote the following late entry for 12/03/10, ""7P (7:00 p.m.) late entry for 12/3/10 Pt (patient) was aware of procedure I and D and consented for procedure."" - During a telephone interview with Employee #6 at 1:25 p.m. on 12/09/10, he stated he had no knowledge of the procedure prior to being instructed to administer pain medication at 3:00 p.m. on 12/03/10, which he did, documenting that the resident complained of pain at a level ""8"" on a scale of ""1 to 10"" and that she was crying. He stated he then left the room and was not present during the procedure, as the CNP was being assisted by a NP student who was with her. He stated he did not hear the procedure discussed with the resident nor did he have any knowledge of the resident giving consent for the procedure, and he reported the resident's MPOA was notified by him after the procedure was completed. He stated that, in his entries into the record, he had written the resident and her MPOA gave consent to the procedure (as noted in the nursing notes by Employee #6 referenced above). However, Employee #6 stated to this surveyor that he wrote these entries because the CNP told him that she had received permission although, after talking to the MPOA, he realized the consent of the MPOA had not been received prior to the procedure. Employee #6 did not witness Resident #118 giving informed consent for the CNP to perform the procedure. Employee #6 stated that, when he assessed the resident after the procedure at 6:30 p.m. on 12/03/10, she had a dressing to her left lower leg which was elevated, and she told him the pain medication had helped. He stated that, shortly after he returned to the nurse's station, a nursing assistant (Employee #9) notified him that the resident's dressing was saturated with blood. He told the CNP, and the CNP and the NP student went in and redressed the wound. (Note there was no mention anywhere in the resident's record, by either the LPNs or the CNP, that the resident's dressing was saturated with blood or that her surgical wounds needed to be redressed.) Employee #6 reported having been told by the CNP that she had contacted the resident's attending physician and had received orders to transfer the resident to the hospital emergency room (ER) for evaluation. An ambulance was called, and the resident was transported at 7:00 p.m. on 12/03/10. -- 4. The ER record dated 12/03/10 stated, ""... palm sized hematoma left medial calf area, not circumferential ... (two incision sites ... packing removed, no active bleeding, both cavities probed, 4 cm deep and no apparent tunneling between the two. Both cavities irrigated with normal saline until clear return noted on multiple irrigations, repacked with [MEDICATION NAME] gauze to help maintain tamponade effect, dressing applied)."" At 8:35 p.m. on 12/03/10, the resident's white blood count was high (19.7, with normal range of 3.0 - 11.0) and her PT was 23.3. The resident returned to the facility at 1:00 a.m. on 12/04/10 with instructions for a revisit in two (2) days. -- 5. A physician's progress note, dated 12/05/10, stated, ""Came in to inspect hematoma and incisions. I was informed of incision /p (symbol for 'after') it was done."" After the physician was notified of the I&D at approximately 6:30 p.m. on 12/03/10, all further treatment was done by him. -- 6. During an interview with the director of nurses at 12:40 p.m. on 12/09/10, she reported the CNP's services were terminated immediately after the facility learned of this incident and that the CNP had not notified either the resident's family (MPOA) or the physician prior to performing the procedure. She acknowledged Resident #118's record contained no evidence that informed consent was obtained prior to the procedure being done. .",2014-04-01
11343,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-12-09,157,D,,,OEY611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to ensure, for one (1) of seven (7) sampled residents, the physician was notified of an acute change of condition (the presence of a large hematoma), and failed to consult the physician and notify an interested family member prior to a significant alteration in treatment. Resident #118 (who had multiple comorbidities and was on anticoagulation therapy) developed a large hematoma on her left lower extremity, and the facility failed to notify the attending physician of the hematoma. The facility's certified nurse practitioner (CNP) performed an invasive surgical procedure (incision and drainage) on the hematoma without consulting with the attending physician and without informing an interested family member (whom the resident designated to serve as her medical power of attorney representative - MPOA) prior to performing the procedure. The physician and the MPOA were contacted after the procedure resulted in significant bleeding, which necessitated a transfer to the hospital emergency room for additional procedures and which may have been a factor in her death less than seventy-two (72) hours later. Resident identifier: #118. Facility census: 117. Findings include: a) Resident #118 1. A review of Resident #118's closed medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE], and her [DIAGNOSES REDACTED].#), history of venous [MEDICAL CONDITION] (blood clots) and embolism (a mass, such as a detached blood clot, that travels through the bloodstream and becomes lodged in a vessel, obstructing blood flow), [MEDICAL CONDITION], embolism and [MEDICAL CONDITION] of unspecified artery, [MEDICAL CONDITION], and coronary [MEDICAL CONDITION] unspecified type vessel native graft. This resident had been determined by her attending physician to have the capacity to understand and make informed healthcare decisions, and she was described in her nursing notes daily as being alert / oriented and able to make her needs known. In an interview with the social worker (Employee #3) at 3:15 p.m. on 12/08/10, she verified Resident #118 had capacity, although she stated Resident #118's son / MPOA was involved in the resident's care, usually assisted her in decision making, received notices of the care plan conferences, and was notified of changes in her care and health status. This was reflected in her medical record by his signature on various consent forms (e.g., flu vaccine, etc.), her readmission papers after hospitalization , bedhold notices, and notations in nursing notes showing him being notified about changes in her status and/or treatment. -- 2. At 10:55 a.m. on 12/02/10, Resident #118 complained of leg pain and was found to have a hematoma (pocket or localized collection of blood outside of a blood vessel) on her left lower leg. The CNP, who was present in the facility, assessed the hematoma and ordered a stat (immediate) PT/INR and ice packs to the area. The physician was notified of the laboratory results per the nursing notes, but there was no evidence he was made aware of the presence of the hematoma. -- 3. A review of the medical record found that, at 3:00 p.m. on 12/03/10, the CNP performed an incision and drainage (I&D) on Resident #118's hematoma while at the facility, with two (2) incisions being made. There was no evidence in the medical record that the attending physician had been notified of either the initial assessment of a large hematoma on the resident's lower leg on 12/02/10, or of the decision to proceed with the I&D on 12/03/10, even though the resident had been on long-term [MEDICATION NAME] therapy, had a [DIAGNOSES REDACTED]. - A progress note, dated 12/02/10 and electronically signed by the CNP at 5:34 p.m. on 12/03/10, stated under the heading ""Physical Exam"", ""... general appearance, obese and alert oriented x 3 female in mild amount of distress due to pain left leg-inner aspect. ..."" Under the heading ""Plan"", the CNP recorded, ""A return visit is indicated in 1 day. Resident is stable - hematoma not enlarging at present. ? (unknown) etiology but appears no significant trauma. Most likely due to capillary fragility and [MEDICATION NAME] (sic) tx (treatment). No severe pain. Will elevate and Ice (sic) area and fu (follow-up) (sic) 24 hours and will treat conservatively."" - A subsequent progress note, dated 12/03/10 and electronically signed by the CNP at 5:40 p.m. on 12/03/10, stated under the heading ""Chief Complaint"", ""FU (follow-up) hematoma left leg. Resident evaluated yesterday for hematoma (etiology unknown) - reevaluated today. Resident was complaining of increased pain, hematoma had doubled in size, and skin was cold to touch. INR 2.1. Stated had increased pain if moved leg or pressure applied."" Under the heading ""ROS"" (review of systems) was recorded, ""I reviewed the medical, surgical, family, social, medication, food allergy and patient code status histories. ..."" Under the heading ""Physical Exam"" was recorded, ""... general appearance, obese and alert oriented x 3-very pleasant female in distress due to pain left lower leg. ... Large hematoma which has at least doubled in size since initial evaluation yesterday. Skin is extremely taunt (sic) and area is exquisitely tender to palpation. Area measures 5 cmx4cm (sic) and is circumfrential (sic). ..."" Under the heading ""Services Performed"", the CNP recorded, ""Resident is stable but (sic) am concerned about swelling, pain and coolness of skin over hematoma. (15:00) (3:00 p.m.) Residents (sic) vs (vital signs) stable - INR 2.0 (done this am). Due to fact resident may be developing [DIAGNOSES REDACTED], I attempt (sic) to aspirate hematoma. I clean (sic) hematoma with [MEDICATION NAME] (sic) and attempt to make small incision to drain collected blood. I am (sic) successful in draining about 30 cc's but area is still very large and painful. A small incision is made (sic) posterior aspect of hematoma and (sic) am able to evaluate large amount of formed clots from hematoma. ... area is packed ... Sterile dressing was applied with mild amount of pressure. Hemostasis is obtained and resident states (sic) has complete pain relief. ... 16:45 (4:45 p.m.) call (sic) son (name) and discuss (sic) treatment - he agrees to evacuation of hematoma and packing area. Also agrees with dose of antibiotic. Resident is reevaluated at 17:00 (5:00 p.m.) - No bleeding from area. ... Due to fact resident has multiple comorbidities and is on [MEDICATION NAME] (sic), it is determined by Dr. (name) and myself, (sic) that resident would be better evaluated if was at hospital. Son was notified and I discussed this with resident, who agrees to go ... Will be transferred by EMS (emergency medical services)."" There was no evidence in either progress note that the CNP consulted with the attending physician prior to incising and draining the resident's hematoma. -- 4. A nursing note entered by a licensed practical nurse (LPN - Employee #6) at 3:00 p.m. on 12/03/10 stated, ""... NP requested the pain med during I&D of hematoma to L (left) extremity. I administered pain (med) and left room while procedure was taking place. (After) procedure pt's (patient's) leg kept elevated with dressing in place. Pedal pulse checks (+)."" Subsequent nursing notes on 12/03/10 stated: - At 6:15 p.m., Employee #6 wrote, ""Verbal consent to evacuate hematoma to LLE (left lower extremity) by (name) MPOA ..."" - At 6:30 p.m., Employee #8 (another LPN) wrote, ""VSS (vital signs stable) - 131/55, HR 74, R - 18, Temp 97.2. Resident exhibited an episode of vomiting - reports (symbol for 'no') nausea at this time. Pedal pulses present and easy palpable. (Symbol for 'no') c/o (complaint of) pain, (symbol for 'no') numbness or tingling in L lower extremity. Exhibits ability to move all toes on L foot. L leg remains elevated with application of ice as ordered, (symbol for 'no') [MEDICAL CONDITION] noted, (symbol for 'no') redness, (symbol for 'no') bleeding. Small amount of serosanguiness (sic) (serosanguineous drainage) noted on external bandage / ice pack. Nurse Practitionor (sic) was aware of PT/INR lab drawn 12/2/10 - (Symbol for 'no') N/O (new orders) at this time - MPOA aware of information - Call light in reach of resident, in bed resting."" Employee #6 also wrote the following late entry for 12/03/10, ""7P (7:00 p.m.) late entry for 12/3/10 Pt (patient) was aware of procedure I and D and consented for procedure."" - During a telephone interview with Employee #6 at 1:25 p.m. on 12/09/10, he stated he had no knowledge of the procedure prior to being instructed to administer pain medication at 3:00 p.m. on 12/03/10, which he did, documenting that the resident complained of pain at a level ""8"" on a scale of ""1 to 10"" and that she was crying. He stated he then left the room and was not present during the procedure, as the CNP was being assisted by a NP student who was with her. He stated he did not hear the procedure discussed with the resident nor did he have any knowledge of the resident giving consent for the procedure, and he reported the resident's MPOA was notified by him after the procedure was completed. He stated that, in his entries into the record, he had written the resident and her MPOA gave consent to the procedure (as noted in the nursing notes by Employee #6 referenced above). However, Employee #6 stated to this surveyor that he wrote these entries because the CNP told him that she had received permission although, after talking to the MPOA, he realized the consent of the MPOA had not been received prior to the procedure. Employee #6 did not witness Resident #118 giving informed consent for the CNP to perform the procedure. Employee #6 stated that, when he assessed the resident after the procedure at 6:30 p.m. on 12/03/10, she had a dressing to her left lower leg which was elevated, and she told him the pain medication had helped. He stated that, shortly after he returned to the nurse's station, a nursing assistant (Employee #9) notified him that the resident's dressing was saturated with blood. He told the CNP, and the CNP and the NP student went in and redressed the wound. (Note there was no mention anywhere in the resident's record, by either the LPNs or the CNP, that the resident's dressing was saturated with blood or that her surgical wounds needed to be redressed.) Employee #6 reported having been told by the CNP that she had contacted the resident's attending physician and had received orders to transfer the resident to the hospital emergency room (ER) for evaluation. An ambulance was called, and the resident was transported at 7:00 p.m. on 12/03/10. -- 6. The ER record dated 12/03/10 stated, ""... palm sized hematoma left medial calf area, not circumferential ... (two incision sites ... packing removed, no active bleeding, both cavities probed, 4 cm deep and no apparent tunneling between the two. Both cavities irrigated with normal saline until clear return noted on multiple irrigations, repacked with [MEDICATION NAME] gauze to help maintain tamponade effect, dressing applied)."" At 8:35 p.m. on 12/03/10, the resident's white blood count was high (19.7, with normal range of 3.0 - 11.0) and her PT was 23.3. The resident returned to the facility at 1:00 a.m. on 12/04/10 with instructions for a revisit in two (2) days. -- A physician's progress note, dated 12/05/10, stated, ""Came in to inspect hematoma and incisions. I was informed of incision /p (symbol for 'after') it was done."" -- 8. During an interview with the director of nurses at 12:40 p.m. on 12/09/10, she reported the CNP's services were terminated immediately after the facility learned of this incident and that the CNP had not notified either the resident's family (MPOA) or the physician prior to performing the procedure. She acknowledged Resident #118's record contained no evidence that informed consent was obtained prior to the procedure being done. The termination of the services of the CNP was confirmed by the administrator during the exit conference. .",2014-04-01
11344,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-12-09,224,G,,,OEY611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to assure one (1) of seven (7) sampled residents received appropriate services necessary to avoid physical harm. The facility's certified nurse practitioner (CNP) performed an invasive surgical procedure (incision and drainage of a large hematoma) on a high-risk resident with multiple comorbidities and on anticoagulation therapy, without evidence of having obtained informed consent from the resident, consulting with the resident's attending physician, and informing an interested family member (whom the resident designated to serve as her medical power of attorney representative - MPOA) prior to performing the procedure. This invasive procedure resulted in harm to the resident, who experienced increased pain, anxiety, and bleeding, which necessitated a transfer to the hospital emergency room for additional procedures and which may have been a factor in her death less than seventy-two (72) hours later. Resident identifier: #118. Facility census: 117. Findings include: a) Resident #118 1. A review of Resident #118's closed medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE], and her [DIAGNOSES REDACTED].#), history of venous [MEDICAL CONDITION] (blood clots) and embolism (a mass, such as a detached blood clot, that travels through the bloodstream and becomes lodged in a vessel, obstructing blood flow), [MEDICAL CONDITION], embolism and [MEDICAL CONDITION] of unspecified artery, [MEDICAL CONDITION], and coronary [MEDICAL CONDITION] unspecified type vessel native graft. This resident had been determined by her attending physician to have the capacity to understand and make informed healthcare decisions, and she was described in her nursing notes daily as being alert / oriented and able to make her needs known. In an interview with the social worker (Employee #3) at 3:15 p.m. on [DATE], she verified Resident #118 had capacity, although she stated Resident #118's son / MPOA was involved in the resident's care, usually assisted her in decision making, received notices of the care plan conferences, and was notified of changes in her care and health status. This was reflected in her medical record by his signature on various consent forms (e.g., flu vaccine, etc.), her readmission papers after hospitalization , bedhold notices, and notations in nursing notes showing him being notified about changes in her status and/or treatment. -- 2. The resident's cardiovascular disease was being treated with long-term [MEDICATION NAME] therapy, which included regular monitoring of her [MEDICATION NAME] time (PT) and INR. PT evaluates the ability of blood to clot properly; INR (International normalized ratio) is a system established by the World Health Organization (WHO) and the International Committee on [MEDICAL CONDITION] and Hemostasis for reporting the results of blood coagulation (clotting) tests. The lab's normal ranges for these tests were PT - 9.2 to 11.8 and INR - 2.0 to 3.0. Record review revealed the following lab results and adjustments made to her [MEDICATION NAME] order in November and [DATE]: Date - [MEDICATION NAME] Dosage - PT / INR - New Order [DATE] - 2.5 mg daily - 42.1 / 4.3 - hold x 2 days [DATE] - ([MEDICATION NAME] held) - 39.8 / 4.1 - [MEDICATION NAME] 2.0 mg daily [DATE] - 2.0 mg daily - 34.5 / 3.4 - [MEDICATION NAME] 1.5 mg daily [DATE] - 1.5 mg daily - 25.8 / 2.4 - same [DATE] - 1.5 mg daily - 27.3 / 2.5 - same [DATE] (at 12:00 p.m.) - 1.5 mg daily - 23.0 / 2.0 - same [DATE] (at 8:10 p.m.) - 1.5 mg daily - 23.3 / 2.3 - same On [DATE], the physician gave orders to discontinue the [MEDICATION NAME] and obtain a repeat PT/INR. -- 3. At 10:55 a.m. on [DATE], Resident #118 complained of leg pain and was found to have a hematoma (pocket or localized collection of blood outside of a blood vessel) on her left lower leg which the resident stated was due to being held there by staff while she was given catheter care. An incident report was completed, the resident's allegation was reported to the State survey and certification agency, and the facility conducted an internal investigation into the origin of the hematoma. The facility's internal investigation was unable to determine the cause of the injury, but the CNP and the resident's MPOA were notified of the incident. The CNP, who was present in the facility, assessed the hematoma and ordered a stat (immediate) PT/INR and ice packs to the area. The physician was notified of the laboratory results per the nursing notes, but there was no evidence that he was made aware of the presence of the hematoma. -- 4. A review of the medical record found that, at 3:00 p.m. on [DATE], the CNP performed an incision and drainage (I&D) on Resident #118's hematoma while at the facility, with two (2) incisions being made. There was no evidence in the medical record that the attending physician had been notified of either the initial assessment of a large hematoma on the resident's lower leg on [DATE], or of the decision to proceed with the I&D on [DATE], even though the resident had been on long-term [MEDICATION NAME] therapy, had a [DIAGNOSES REDACTED]. - A progress note, dated [DATE] and electronically signed by the CNP at 5:34 p.m. on [DATE], stated under the heading ""Physical Exam"", ""... general appearance, obese and alert oriented x 3 female in mild amount of distress due to pain left leg-inner aspect. ..."" Under the heading ""Plan"", the CNP recorded, ""A return visit is indicated in 1 day. Resident is stable - hematoma not enlarging at present. ? (unknown) etiology but appears no significant trauma. Most likely due to capillary fragility and [MEDICATION NAME] (sic) tx (treatment). No severe pain. Will elevate and Ice (sic) area and fu (follow-up) (sic) 24 hours and will treat conservatively."" - A subsequent progress note, dated [DATE] and electronically signed by the CNP at 5:40 p.m. on [DATE], stated under the heading ""Chief Complaint"", ""FU (follow-up) hematoma left leg. Resident evaluated yesterday for hematoma (etiology unknown) - reevaluated today. Resident was complaining of increased pain, hematoma had doubled in size, and skin was cold to touch. INR 2.1. Stated had increased pain if moved leg or pressure applied."" Under the heading ""ROS"" (review of systems) was recorded, ""I reviewed the medical, surgical, family, social, medication, food allergy and patient code status histories. ..."" Under the heading ""Physical Exam"" was recorded, ""... general appearance, obese and alert oriented x 3-very pleasant female in distress due to pain left lower leg. ... Large hematoma which has at least doubled in size since initial evaluation yesterday. Skin is extremely taunt (sic) and area is exquisitely tender to palpation. Area measures 5 cmx4cm (sic) and is circumfrential (sic). ..."" Under the heading ""Services Performed"", the CNP recorded, ""Resident is stable but (sic) am concerned about swelling, pain and coolness of skin over hematoma. (15:00) (3:00 p.m.) Residents (sic) vs (vital signs) stable - INR 2.0 (done this am). Due to fact resident may be developing [DIAGNOSES REDACTED], I attempt (sic) to aspirate hematoma. I clean (sic) hematoma with [MEDICATION NAME] (sic) and attempt to make small incision to drain collected blood. I am (sic) successful in draining about 30 cc's but area is still very large and painful. A small incision is made (sic) posterior aspect of hematoma and (sic) am able to evaluate large amount of formed clots from hematoma. ... area is packed ... Sterile dressing was applied with mild amount of pressure. Hemostasis is obtained and resident states (sic) has complete pain relief. ... 16:45 (4:45 p.m.) call (sic) son (name) and discuss (sic) treatment - he agrees to evacuation of hematoma and packing area. Also agrees with dose of antibiotic. Resident is reevaluated at 17:00 (5:00 p.m.) - No bleeding from area. ... Due to fact resident has multiple comorbidities and is on [MEDICATION NAME] (sic), it is determined by Dr. (name) and myself, (sic) that resident would be better evaluated if was at hospital. Son was notified and I discussed this with resident, who agrees to go ... Will be transferred by EMS (emergency medical services)."" - There was no evidence in either progress note that the CNP consulted with the attending physician prior to incising and draining the resident's hematoma. -- 5. A nursing note entered by a licensed practical nurse (LPN - Employee #6) at 3:00 p.m. on [DATE] stated, ""... NP requested the pain med during I&D of hematoma to L (left) extremity. I administered pain (med) and left room while procedure was taking place. (After) procedure pt's (patient's) leg kept elevated with dressing in place. Pedal pulse checks (+)."" Subsequent nursing notes on [DATE] stated: - At 6:15 p.m., Employee #6 wrote, ""Verbal consent to evacuate hematoma to LLE (left lower extremity) by (name) MPOA ..."" - At 6:30 p.m., Employee #8 (another LPN) wrote, ""VSS (vital signs stable) - ,[DATE], HR 74, R - 18, Temp 97.2. Resident exhibited an episode of vomiting - reports (symbol for 'no') nausea at this time. Pedal pulses present and easy palpable. (Symbol for 'no') c/o (complaint of) pain, (symbol for 'no') numbness or tingling in L lower extremity. Exhibits ability to move all toes on L foot. L leg remains elevated with application of ice as ordered, (symbol for 'no') [MEDICAL CONDITION] noted, (symbol for 'no') redness, (symbol for 'no') bleeding. Small amount of serosanguiness (sic) (serosanguineous drainage) noted on external bandage / ice pack. Nurse Practitionor (sic) was aware of PT/INR lab drawn [DATE] - (Symbol for 'no') N/O (new orders) at this time - MPOA aware of information - Call light in reach of resident, in bed resting."" Employee #6 also wrote the following late entry for [DATE], ""7P (7:00 p.m.) late entry for [DATE] Pt (patient) was aware of procedure I and D and consented for procedure."" - During a telephone interview with Employee #6 at 1:25 p.m. on [DATE], he stated he had no knowledge of the procedure prior to being instructed to administer pain medication at 3:00 p.m. on [DATE], which he did, documenting that the resident complained of pain at a level ""8"" on a scale of ""1 to 10"" and that she was crying. He stated he then left the room and was not present during the procedure, as the CNP was being assisted by a NP student who was with her. He stated he did not hear the procedure discussed with the resident nor did he have any knowledge of the resident giving consent for the procedure, and he reported the resident's MPOA was notified by him after the procedure was completed. He stated that, in his entries into the record, he had written the resident and her MPOA gave consent to the procedure (as noted in the nursing notes by Employee #6 referenced above). However, Employee #6 stated to this surveyor that he wrote these entries because the CNP told him that she had received permission although, after talking to the MPOA, he realized the consent of the MPOA had not been received prior to the procedure. Employee #6 did not witness Resident #118 giving informed consent for the CNP to perform the procedure. Employee #6 stated that, when he assessed the resident after the procedure at 6:30 p.m. on [DATE], she had a dressing to her left lower leg which was elevated, and she told him the pain medication had helped. He stated that, shortly after he returned to the nurse's station, a nursing assistant (Employee #9) notified him that the resident's dressing was saturated with blood. He told the CNP, and the CNP and the NP student went in and redressed the wound. (Note there was no mention anywhere in the resident's record, by either the LPNs or the CNP, that the resident's dressing was saturated with blood or that her surgical wounds needed to be redressed.) Employee #6 reported having been told by the CNP that she had contacted the resident's attending physician and had received orders to transfer the resident to the hospital emergency room (ER) for evaluation. An ambulance was called, and the resident was transported at 7:00 p.m. on [DATE]. -- 6. The ER record dated [DATE] stated, ""... palm sized hematoma left medial calf area, not circumferential ... (two incision sites ... packing removed, no active bleeding, both cavities probed, 4 cm deep and no apparent tunneling between the two. Both cavities irrigated with normal saline until clear return noted on multiple irrigations, repacked with [MEDICATION NAME] gauze to help maintain tamponade effect, dressing applied)."" At 8:35 p.m. on [DATE], the resident's white blood count was high (19.7, with normal range of 3.0 - 11.0) and her PT was 23.3. -- 7. The resident returned to the facility at 1:00 a.m. on [DATE] with instructions for a revisit in two (2) days. At 7:00 a.m. on [DATE], a nursing note stated, ""Dressing to incision site left leg soaked thru with serosanguineous fluid. Replaced old dressings."" At 11:45 a.m. on [DATE], the attending physician was notified of the dressing change and gave telephone orders for dressing changes, to discontinue [MEDICATION NAME], and to obtain a repeat PT/INR on Monday. The MPOA was notified of these orders. At 6:00 p.m. on [DATE], the physician, when notified that ""... area to left leg slightly red warm and hard around wound"", gave telephone orders for an antibiotic. The vital sign sheet from [DATE] to [DATE] recorded her temperature between 96.1 and 98.3 degrees Fahrenheit (F) and her blood pressures between ,[DATE] - ,[DATE]. At 11:50 a.m. on [DATE], the physician visited the resident and wrote new orders to include discontinuing the [MEDICATION NAME] (again) and starting [MEDICATION NAME]-coated aspirin 325 mg by mouth daily. A physician's progress note, dated [DATE], stated, ""Came in to inspect hematoma and incisions. I was informed of incision /p (symbol for 'after') it was done."" After the physician was notified of the I&D at approximately 6:30 p.m. on [DATE], all further treatment was done by him. Thereafter, there were only routine entries in the resident's medical record until 1:45 a.m. on [DATE], when the resident was found unresponsive and had expired. The death certificate stated the cause of death was ""Acute [MEDICAL CONDITION]"". No autopsy was performed to ascertain the cause of the acute [MEDICAL CONDITION]. -- 7. According to Medline Plus, a service of the U.S. National Library of Medicine, National Institutes of Health, a [MEDICAL CONDITION] (or stroke) ""is a medical emergency. [MEDICAL CONDITION] happen when blood flow to your brain stops. Within minutes, brain cells begin to die. There are two kinds of stroke. The more common kind, called ischemic stroke, is caused by a blood clot that blocks or plugs a blood vessel in the brain. ..."" (Internet reference - ) -- 8. During an interview with the director of nurses at 12:40 p.m. on [DATE], she reported the CNP's services were terminated immediately after the facility learned of this incident and that the CNP had not notified either the resident's family (MPOA) or the physician prior to performing the procedure. She acknowledged Resident #118's record contained no evidence that informed consent was obtained prior to the procedure being done. She acknowledged that the record indicated Resident #118 had several [DIAGNOSES REDACTED]. She also stated this and the resident's resulting transfer to the ER were the reasons she had the event reported to the State survey and certification agency as an ""unusual occurrence"". She agreed, after discussion with the surveyor, that the facility would amend their report to an allegation of neglect and do a formal investigation. The termination of the services of the CNP was confirmed by the administrator during the exit conference. .",2014-04-01
11345,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-12-09,225,D,,,OEY611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to immediately report to State agencies and/or thoroughly investigate an incident involving the neglect of one (1) of seven (7) sampled residents. The facility's certified nurse practitioner (CNP) performed an invasive surgical procedure (incision and drainage of a hematoma) on a high-risk resident with multiple comorbidities and on anticoagulation therapy, without evidence of having obtained informed consent from the resident, consulting with the resident's attending physician, and informing an interested family member (whom the resident designated to serve as her medical power of attorney representative - MPOA) prior to performing the procedure. This invasive procedure resulted in harm to the resident, who experienced increased pain, anxiety, and bleeding, which necessitated a transfer to the hospital emergency room for additional procedures and which may have been a factor in her death less than seventy-two (72) hours later. This event was reported to the State survey and certification agency as an ""unusual occurrence"" without evidence of a thorough investigation. Resident identifier: #118. Facility census: 117. Findings include: a) Resident #118 1. A review of Resident #118's closed medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE], and her [DIAGNOSES REDACTED].#), history of venous [MEDICAL CONDITION] (blood clots) and embolism (a mass, such as a detached blood clot, that travels through the bloodstream and becomes lodged in a vessel, obstructing blood flow), [MEDICAL CONDITION], embolism and [MEDICAL CONDITION] of unspecified artery, [MEDICAL CONDITION], and coronary [MEDICAL CONDITION] unspecified type vessel native graft. This resident had been determined by her attending physician to have the capacity to understand and make informed healthcare decisions, and she was described in her nursing notes daily as being alert / oriented and able to make her needs known. In an interview with the social worker (Employee #3) at 3:15 p.m. on [DATE], she verified Resident #118 had capacity, although she stated Resident #118's son / MPOA was involved in the resident's care, usually assisted her in decision making, received notices of the care plan conferences, and was notified of changes in her care and health status. This was reflected in her medical record by his signature on various consent forms (e.g., flu vaccine, etc.), her readmission papers after hospitalization , bedhold notices, and notations in nursing notes showing him being notified about changes in her status and/or treatment. -- 2. At 10:55 a.m. on [DATE], Resident #118 complained of leg pain and was found to have a hematoma (pocket or localized collection of blood outside of a blood vessel) on her left lower leg which the resident stated was due to being held there by staff while she was given catheter care. An incident report was completed, the resident's allegation was reported to the State survey and certification agency, and the facility conducted an internal investigation into the origin of the hematoma. The facility's internal investigation was unable to determine the cause of the injury, but the CNP and the resident's MPOA were notified of the incident. The CNP, who was present in the facility, assessed the hematoma and ordered a stat (immediate) PT/INR and ice packs to the area. The physician was notified of the laboratory results per the nursing notes, but there was no evidence that he was made aware of the presence of the hematoma. -- 3. A review of the medical record found that, at 3:00 p.m. on [DATE], the CNP performed an incision and drainage (I&D) on Resident #118's hematoma while at the facility, with two (2) incisions being made. There was no evidence in the medical record that the attending physician had been notified of either the initial assessment of a large hematoma on the resident's lower leg on [DATE], or of the decision to proceed with the I&D on [DATE], even though the resident had been on long-term [MEDICATION NAME] therapy, had a [DIAGNOSES REDACTED]. - A progress note, dated [DATE] and electronically signed by the CNP at 5:34 p.m. on [DATE], stated under the heading ""Physical Exam"", ""... general appearance, obese and alert oriented x 3 female in mild amount of distress due to pain left leg-inner aspect. ..."" Under the heading ""Plan"", the CNP recorded, ""A return visit is indicated in 1 day. Resident is stable - hematoma not enlarging at present. ? (unknown) etiology but appears no significant trauma. Most likely due to capillary fragility and [MEDICATION NAME] (sic) tx (treatment). No severe pain. Will elevate and Ice (sic) area and fu (follow-up) (sic) 24 hours and will treat conservatively."" - A subsequent progress note, dated [DATE] and electronically signed by the CNP at 5:40 p.m. on [DATE], stated under the heading ""Chief Complaint"", ""FU (follow-up) hematoma left leg. Resident evaluated yesterday for hematoma (etiology unknown) - reevaluated today. Resident was complaining of increased pain, hematoma had doubled in size, and skin was cold to touch. INR 2.1. Stated had increased pain if moved leg or pressure applied."" Under the heading ""ROS"" (review of systems) was recorded, ""I reviewed the medical, surgical, family, social, medication, food allergy and patient code status histories. ..."" Under the heading ""Physical Exam"" was recorded, ""... general appearance, obese and alert oriented x 3-very pleasant female in distress due to pain left lower leg. ... Large hematoma which has at least doubled in size since initial evaluation yesterday. Skin is extremely taunt (sic) and area is exquisitely tender to palpation. Area measures 5 cmx4cm (sic) and is circumfrential (sic). ..."" Under the heading ""Services Performed"", the CNP recorded, ""Resident is stable but (sic) am concerned about swelling, pain and coolness of skin over hematoma. (15:00) (3:00 p.m.) Residents (sic) vs (vital signs) stable - INR 2.0 (done this am). Due to fact resident may be developing [DIAGNOSES REDACTED], I attempt (sic) to aspirate hematoma. I clean (sic) hematoma with [MEDICATION NAME] (sic) and attempt to make small incision to drain collected blood. I am (sic) successful in draining about 30 cc's but area is still very large and painful. A small incision is made (sic) posterior aspect of hematoma and (sic) am able to evaluate large amount of formed clots from hematoma. ... area is packed ... Sterile dressing was applied with mild amount of pressure. Hemostasis is obtained and resident states (sic) has complete pain relief. ... 16:45 (4:45 p.m.) call (sic) son (name) and discuss (sic) treatment - he agrees to evacuation of hematoma and packing area. Also agrees with dose of antibiotic. Resident is reevaluated at 17:00 (5:00 p.m.) - No bleeding from area. ... Due to fact resident has multiple comorbidities and is on [MEDICATION NAME] (sic), it is determined by Dr. (name) and myself, (sic) that resident would be better evaluated if was at hospital. Son was notified and I discussed this with resident, who agrees to go ... Will be transferred by EMS (emergency medical services)."" -- 4. A nursing note entered by a licensed practical nurse (LPN - Employee #6) at 3:00 p.m. on [DATE] stated, ""... NP requested the pain med during I&D of hematoma to L (left) extremity. I administered pain (med) and left room while procedure was taking place. (After) procedure pt's (patient's) leg kept elevated with dressing in place. Pedal pulse checks (+)."" Subsequent nursing notes on [DATE] stated: - At 6:15 p.m., Employee #6 wrote, ""Verbal consent to evacuate hematoma to LLE (left lower extremity) by (name) MPOA ..."" - At 6:30 p.m., Employee #8 (another LPN) wrote, ""VSS (vital signs stable) - ,[DATE], HR 74, R - 18, Temp 97.2. Resident exhibited an episode of vomiting - reports (symbol for 'no') nausea at this time. Pedal pulses present and easy palpable. (Symbol for 'no') c/o (complaint of) pain, (symbol for 'no') numbness or tingling in L lower extremity. Exhibits ability to move all toes on L foot. L leg remains elevated with application of ice as ordered, (symbol for 'no') [MEDICAL CONDITION] noted, (symbol for 'no') redness, (symbol for 'no') bleeding. Small amount of serosanguiness (sic) (serosanguineous drainage) noted on external bandage / ice pack. Nurse Practitionor (sic) was aware of PT/INR lab drawn [DATE] - (Symbol for 'no') N/O (new orders) at this time - MPOA aware of information - Call light in reach of resident, in bed resting."" Employee #6 also wrote the following late entry for [DATE], ""7P (7:00 p.m.) late entry for [DATE] Pt (patient) was aware of procedure I and D and consented for procedure."" - During a telephone interview with Employee #6 at 1:25 p.m. on [DATE], he stated he had no knowledge of the procedure prior to being instructed to administer pain medication at 3:00 p.m. on [DATE], which he did, documenting that the resident complained of pain at a level ""8"" on a scale of ""1 to 10"" and that she was crying. He stated he then left the room and was not present during the procedure, as the CNP was being assisted by a NP student who was with her. He stated he did not hear the procedure discussed with the resident nor did he have any knowledge of the resident giving consent for the procedure, and he reported the resident's MPOA was notified by him after the procedure was completed. He stated that, in his entries into the record, he had written the resident and her MPOA gave consent to the procedure (as noted in the nursing notes by Employee #6 referenced above). However, Employee #6 stated to this surveyor that he wrote these entries because the CNP told him that she had received permission although, after talking to the MPOA, he realized the consent of the MPOA had not been received prior to the procedure. Employee #6 did not witness Resident #118 giving informed consent for the CNP to perform the procedure. Employee #6 stated that, when he assessed the resident after the procedure at 6:30 p.m. on [DATE], she had a dressing to her left lower leg which was elevated, and she told him the pain medication had helped. He stated that, shortly after he returned to the nurse's station, a nursing assistant (Employee #9) notified him that the resident's dressing was saturated with blood. He told the CNP, and the CNP and the NP student went in and redressed the wound. Employee #6 reported having been told by the CNP that she had contacted the resident's attending physician and had received orders to transfer the resident to the hospital emergency room (ER) for evaluation. An ambulance was called, and the resident was transported at 7:00 p.m. on [DATE]. -- 5. The ER record dated [DATE] stated, ""... palm sized hematoma left medial calf area, not circumferential ... (two incision sites ... packing removed, no active bleeding, both cavities probed, 4 cm deep and no apparent tunneling between the two. Both cavities irrigated with normal saline until clear return noted on multiple irrigations, repacked with [MEDICATION NAME] gauze to help maintain tamponade effect, dressing applied)."" At 8:35 p.m. on [DATE], the resident's white blood count was high (19.7, with normal range of 3.0 - 11.0) and her PT was 23.3. -- 6. The resident returned to the facility at 1:00 a.m. on [DATE] with instructions for a revisit in two (2) days. At 7:00 a.m. on [DATE], a nursing note stated, ""Dressing to incision site left leg soaked thru with serosanguineous fluid. Replaced old dressings."" At 11:45 a.m. on [DATE], the attending physician was notified of the dressing change and gave telephone orders for dressing changes, to discontinue [MEDICATION NAME], and to obtain a repeat PT/INR on Monday. The MPOA was notified of these orders. At 6:00 p.m. on [DATE], the physician, when notified that ""... area to left leg slightly red warm and hard around wound"", gave telephone orders for an antibiotic. The vital sign sheet from [DATE] to [DATE] recorded her temperature between 96.1 and 98.3 degrees Fahrenheit (F) and her blood pressures between ,[DATE] - ,[DATE]. At 11:50 a.m. on [DATE], the physician visited the resident and wrote new orders to include discontinuing the [MEDICATION NAME] (again) and starting [MEDICATION NAME]-coated aspirin 325 mg by mouth daily. A physician's progress note, dated [DATE], stated, ""Came in to inspect hematoma and incisions. I was informed of incision /p (symbol for 'after') it was done."" After the physician was notified of the I&D at approximately 6:30 p.m. on [DATE], all further treatment was done by him. Thereafter, there were only routine entries in the resident's medical record until 1:45 a.m. on [DATE], when the resident was found unresponsive and had expired. The death certificate stated the cause of death was ""Acute [MEDICAL CONDITION]"". No autopsy was performed to ascertain the cause of the acute [MEDICAL CONDITION]. -- 7. According to Medline Plus, a service of the U.S. National Library of Medicine, National Institutes of Health, a [MEDICAL CONDITION] (or stroke) ""is a medical emergency. [MEDICAL CONDITION] happen when blood flow to your brain stops. Within minutes, brain cells begin to die. There are two kinds of stroke. The more common kind, called ischemic stroke, is caused by a blood clot that blocks or plugs a blood vessel in the brain. ..."" (Internet reference - ) -- 8. During an interview with the director of nurses at 12:40 p.m. on [DATE], she reported the CNP's services were terminated immediately after the facility learned of this incident and that the CNP had not notified either the resident's family (MPOA) or the physician prior to performing the procedure. She acknowledged Resident #118's record contained no evidence that informed consent was obtained prior to the procedure being done. She acknowledged that the record indicated Resident #118 had several [DIAGNOSES REDACTED]. She also stated this and the resident's resulting transfer to the ER were the reasons she had the event reported to the State survey and certification agency as an ""unusual occurrence"". She agreed, after discussion with the surveyor, that the facility would amend their report to an allegation of neglect and do a formal investigation.",2014-04-01
11346,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2011-01-13,157,D,,,I28Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, family interview, and staff interview, the facility failed to provide prompt notification, to the responsible party of one (1) of forty-two (42) Stage II sample residents, after the resident experienced a change in condition. Resident #120 became agitated while in the dining room on 11/12/10, and the nurse aides had to carry the resident back to her room due to her increased agitation, resistance of care, and physically aggressive behaviors. The resident's medical power of attorney representative (MPOA) did not learn of these events until 11/16/10. Resident identifier: #120. Facility census: 113. Findings include: a) Resident #120 On the night of 11/12/10, Resident #120 exhibited agitated behaviors that were atypical for her. According to documentation recorded by a licensed practical nurse (LPN - Employee #114), the resident was in the dining room by herself when she became agitated and started carrying around a wet floor sign, hitting the window of the dining room with the wet floor sign. The resident was soiled also due to incontinence. When nurse aides approached her and tried to get her to her room (in order to provide incontinence care), she became more agitated, hitting and kicking the nurse aides. Nurse aides eventually had to carry the resident from the dining room to her room, in order to change her out of her soiled clothes. On 01/06/11 at approximately 2:00 p.m., the social worker (Employee #134) provided a copy of documentation she had collected on 11/16/10. The documentation stated, ""(Name), daughter and MPOA for (Resident #120), came into the office about 1:25 PM this date and stated that (name of Employee #73), CNA (certified nursing assistant), told her there was a rumor that 3 CNA's (sic) on south side turned in 3 CNAs from north side for abuse of (Resident #120). The story is that Friday, 11/12/10, night (Resident #120) was hitting and combative with staff. In an attempt to get her calmed they restrained her and in the process bruised her pretty bad. (Daughter's name) indicated that she (the resident) has bruising on her left wrist, right wrist, and a dark blue spot further up her right arm. (Employee #73) told (daughter's name) names (sic) of two CNAs, (names of Employees #65 and #54) both of whom work 3-11 shift. (Daughter's name) was also told that one of the CNAs was new. She inquired about the process when something like this happens. It was explained generally about investigating and reporting. She was rather upset understanding (sic) however, her mother's behaviors at times (sic) but was concerned about the bruises. She was assured we would keep her informed. ..."" The resident's daughter became aware of the above incident on 11/16/10, when she came to the facility and Employee #73 approached her with the above information. According to the administrator, the information given to the daughter by Employee #73 did not portray what actually occurred. According to the administrator, Employee #73 did not work on the night of 11/12/10 and had no direct knowledge of what happened, and Employee #73 received a disciplinary action for her actions. On 01/06/11 at approximately 4:00 p.m., the director of nursing (DON) confirmed the facility did not contact the resident's daughter to inform her of what had occurred on 11/12/10. She stated Employee #114 used her nursing judgement on 11/12/10 and elected to not contact the resident's MPOA to inform her of her mother's behavior and of the actions taken to get the resident back to her room and in a more calm state. The DON and the administrator both confirmed the events on 11/12/10 were not typical for the resident. They attributed the increase in aggression to the resident's [DIAGNOSES REDACTED]. .",2014-04-01
11347,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2010-12-22,309,D,,,IX4U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident observation, staff interview, and resident interview, the facility failed to provide necessary care and services for one (1) of a hundred and forty-four (144) residents on the sample. Resident #15 was receiving blood thinners and was observed with excessive bruising to bilateral upper extremities. There was no documentation that the use of blood thinners was being monitored for this resident. Resident identifier: #15. Facility census: 144. Findings include: a) Resident #15 Observation, on 12/21/10 at 10:20 a.m., found Resident #15 sitting on her bed with excessive bruising to her bilateral upper extremities. An interview with Resident #15 revealed she was on blood thinners. Review of the physician's orders [REDACTED]. Review of recent laboratory results, dated 09/09/10 and 11/08/10, found no laboratory results used for monitoring the effectiveness of the blood thinner to regulate clotting. Review of the resident's treatment administration record (TAR) for December 2010 revealed weekly body audits had not been documented for 12/09/10 and 12/16/10. In an interview on 12/22/10 at 4:00 p.m., Resident #15 reported, ""I can barely just touch or scratch myself and I bruise. I am on blood thinners, and I think it needs to be checked. I was going to talk to my doctor about it, but I haven't seen him."" In an interview on 12/22/10 at 5:15 p.m., the director of nursing (DON - Employee #169) reported, ""We know we have a problem with documentation, and we are working on it."" Employee #169 stated the facility had no documentation regarding the bruising on Resident #15's arms. Interview with the licensed practical nurse (LPN) assigned to Resident #15 (Employee #159), on 12/22/10 at 5:20 p.m., revealed he was not aware of any bruising to Resident #15's bilateral upper extremities. .",2014-04-01
11348,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2010-12-22,514,D,,,IX4U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident observation, and staff interview, the facility failed to maintain a complete clinical record for one (1) of a hundred and forty-four (144) residents on the sample. Resident #15 was observed with excessive bruising to bilateral upper extremities, and there was no documentation that two (2) of three (3) weekly body audits had been completed in the month of December 2010. Resident identifier: #15. Facility census: 144. Findings include: a) Resident #15 Observation, on 12/21/10 at 10:20 a.m., found Resident #15 sitting on her bed with excessive bruising to her bilateral upper extremities. An interview with Resident #15 revealed she was on blood thinners. Review of the physician's orders [REDACTED]. Review of the resident's treatment administration record (TAR) for December 2010 revealed weekly body audits had not been documented for 12/09/10 and 12/16/10. In an interview on 12/22/10 at 5:15 p.m., the director of nursing (DON - Employee #169) reported, ""We know we have a problem with documentation, and we are working on it."" Employee #169 stated the facility had no documentation regarding the bruising on Resident #15's arms. (See also citation at F309.)",2014-04-01
11349,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2010-12-22,323,G,,,IX4U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review, review of the facility's self-reported injuries of unknown source and allegations of resident abuse / neglect, and staff interview, the facility failed to provide adequate supervision and/or assistive devices to prevent avoidable accidents with injury for one (1) of eleven (11) sampled residents. Resident #147, who had partial loss of voluntary movement with limitations to range of motion in both legs and feet and who was totally dependent on staff for bed mobility, transfers, and locomotion, was assessed as needing the physical assistance of two (2) persons and a mechanical lift for safe transfers between surfaces. On 09/02/10, Resident #147 was manually transferred on three (3) separate occasions (from wheelchair to shower chair; from shower chair back to wheelchair; and from wheelchair to bed); she complained of leg pain during the second and third manual transfers. In response to her complaints of leg pain during the third manual transfer, the aides notified the nurse; the nurse contacted the physician, who ordered a stat x-ray. The x-ray revealed a displaced acute fracture of the fibula with no indication that the fracture was clinically avoidable, and the resident was subsequently transferred to the hospital on the early morning of 09/03/10. Resident identifier: #147. Facility census: 144. Findings include: a) Resident #147 1. Closed record review, on 12/21/10, revealed this [AGE] year old female was originally admitted to the facility in 2004; her most recent readmission / return to the facility occurred following a hospital stay from 12/03/08 to 12/17/08. - Her most recent comprehensive assessment was an annual assessment with an assessment reference date (ARD) of 02/24/10, in which the assessor recorded the resident as having both short and long-term memory problems with moderately impaired cognitive skills for daily decision-making, and she was able to make herself understood to others and usually understood what others said to her. According to the assessor, Resident #147 had partial loss of voluntary movement with limitations to range of motion in both her legs and her feet; tests for standing and sitting balance were not able to be attempted; she required the extensive physical assistance of one (1) person for bed mobility, bathing, dressing, and personal hygiene; she was totally dependent on two (2) or more persons for transferring, locomotion, and toilet use; she was to be transferred using a mechanical lift; and she was non-ambulatory. Her [DIAGNOSES REDACTED]., anxiety disorder and depression, and chronic obstructive pulmonary disease. The assessor did not identify, as active diagnoses, either osteoporosis or pathological bone fracture, and the assessor did not identify the resident as having any acute episode or flare-up of a recurrent or chronic problem, nor did the assessor indicate the resident had an end-stage disease. As other the ARD of 02/24/10, Resident #147 did not have any falls or fractures in the preceding one hundred-eighty (180) days. - In Resident #147's most recent abbreviated quarterly assessment, with an ARD of 08/11/10, the assessor noted there had been no changes in her memory, cognitive functioning, or ability to communicate. She continued to have partial loss of voluntary movement with limitations to range of motion in both legs and feet; a test for standing balance was not able to be attempted, and a test for sitting balance revealed the need for partial physical support. According to the assessor, she was now totally dependent on one (1) person for bed mobility and toilet use; she was totally dependent on two (2) or more persons for transferring; she required the extensive physical assistance of one (1) person for locomotion, dressing, bathing, and personal hygiene; and she remained non-ambulatory. As other the ARD of 08/11/10, Resident #147 did not have any falls or fractures in the preceding one hundred-eighty (180) days. - Review of her most recent comprehensive care plan (with a print date of 08/18/10) revealed the following problem statement (with a created date of 11/28/07 and a revision date of 10/08/08): ""ADL (activities of daily living) Self (sic) care deficit as evidenced by need of (sic) staff support to complete her self care activities related to physical limitations, trremors (sic), pain and dementia."" Goals associated with this problem statement were: ""Will be clean, dressed, and well groomed daily to promote dignity and psychosocial wellbeing. Will receive assistance necessary to meet ADL needs. Will participate in self-care tasks at the highest practicable level of functioning."" Interventions to meet these goals included: ""Tranfer (sic) with 2 person / Mechanical Lift (sic)."" (This intervention was created / initiated on 01/18/10.) -- 2. A review of Resident #147's nursing notes revealed the following consecutive entries: - On 09/02/10 at 10:20 p.m. - ""Resident c/o (complained of) pain to (L) (left) leg. MD aware. N.O. (new order) for Stat xray (sic) to left leg. MPOA (medical power of attorney representative) aware. Assessment completed to left leg. (Symbol for 'no') bruising, (symbol for 'no') scratches, (symbol for 'no') edema, (symbol for 'no') redness noted. Resident states 'I can't feel my legs'. Xray (sic) obtain (sic) per order. Resident didn't complain of discomfort during x-ray. Xray (sic) to be faxed to nurses (sic) station."" The author, registered nurse (RN) supervisor Employee #134, struck through this entry and labeled it ""error"", although the author did not note the date / time when this correction was made. - On 09/03/10 at 1:00 a.m. - ""C/O (complaint of) pain in left leg. PRN (as needed) analgesic x 1 per order /c (with) No (sic) relief."" - 09/03/10 at 2:30 a.m. - ""Xray (sic) results called to Dr. (name) /c new order noted to send to ER (sic) (emergency room ) for evaluation & ortho (orthopedic) consult d/t fx (fracture) of left fibula. ..."" - 09/03/10 at 3:15 a.m. - ""Left unit via gernie (sic) accompanied by two attendants from ems (emergency medical service) en route to (name of local hospital)."" - After the resident's transfer to the hospital on [DATE], Employee #134 recorded the following series of late entries: - 09/09/10 (no time noted) - ""late (sic) entry for 9/2/10 7:30 p.m. Resident complaint (sic) of pain to left leg. Assessment completed to left leg. (Symbol for 'no') bruising noted. (Symbol for 'no') redness. (Symbol for 'no') edema, or scratches noted to left leg. resident (sic) c/o pain in the knee area. Resident stated 'I can't feel my legs.' Call placed to MD. resident (sic) medicated for pain per order. Will continue to monitor."" - 09/09/10 (no time noted) - ""late (sic) entry for 9/2/10 8:00 p.m. MD return (sic) call obtain (sic) order for stat xray (sic). POA (power of attorney) aware. (Name of mobile imaging company) aware."" - 09/09/10 (no time noted) - ""late (sic) entry for 9/2/10 8:45 p.m. Xray's (sic) obtained, daughter /c resident at bedside. (Symbol for 'no') complaints of pain at this time. Will continue to monitor resident and await the report."" - 09/09/10 (no time noted) - ""late (sic) entry for 9/2/10 10:20 p.m. Resident resting in bed. (Symbol for 'no') discomfort noted. (Symbol for 'no') complaints of pain noted. Awaiting xray (sic) to be faxed to nurses (sic) station. (Symbol for 'no') edema, (symbol for 'no') bruising, (symbol for 'no') redness noted to left leg. Will continue to monitor."" This was the last entry in the resident's nursing notes; she did not return to this facility after being transferred to the hospital on [DATE]. -- 3. The radiology report for Resident #147 from the mobile imaging company, with a ""date of exam"" of ""2010-09-02"" (09/02/10) contained the following impression: ""Left tibia-fibula - Mildly displaced acute fracture of the proximal fibular shaft and fibular head demonstrated."" There was no evidence to reflect this acute displaced fracture of the left fibula of this non-ambulatory resident, who was totally dependent on staff for bed mobility, transferring, and locomotion, was clinically unavoidable (e.g., the result of osteoporosis or a pathological bone fracture). -- 4. A review of the facility's self-reported allegations of resident abuse / neglect and injuries of unknown source, on 12/21/10 beginning at approximately 11:00 a.m., revealed the facility reported Resident #147's fracture as an injury of unknown source to the State survey and certification agency and other State agencies on 09/03/10 as follows: ""Resident complained of 'not being able to feel' her leg. Obtained xray (sic) of left leg and results showed fracture. ..."" The date of the incident was noted to be on 09/02/10 during the 3:00 p.m. to 11:00 p.m. shift (no specific time stated); the location of the incident was noted to be ""Unknown"". - Review of the facility's internal investigation into this fracture of unknown source revealed that, although a discreet causal event could not be isolated, three (3) nursing assistants (Employees #152, #141, and #170) transferred the resident on 09/02/10 without using a mechanical lift as identified in the resident's comprehensive assessment and care plan. - According to a handwritten witness statement by the former interim director of nursing (Employee #171), dated 09/08/10: ""During the termination phase of the disciplinary process for (Employee #152, CNA (certified nursing assistant), regarding (Resident #147) (sic). The employee made the following verbal statements: ""'About 4 pm (sic) (Resident #147) was sitting in w/c (wheelchair) in hallway crying. I asked her what was wrong and (Employee #141, another nursing assistant) said she always cries when she looses (sic) at Bingo. I ask (sic) her if she wanted to take a shower. I took her to the shower room in the wheelchair.' ""'(Employee #170) had stayed until 7:00 PM (sic) to do showers; (Resident #147) was still crying. (Employee #170 and I stood (Resident #147) and pivoted her to the shower chair. I left and came back when shower was done; we dressed her, stood and pivoted her from the shower chair to the wheelchair. I took her back to her room, she usually is only out of bed for an hour. I was going to put her in bed; I did a face to face lift; she wasn't bearing weight but she started saying 'my leg, my leg, set me down. (sic) I set her down and called to (Employee #141) to help me. We transferred her to bed with (Employee #141) behind her, me in front; we stood her and pivoted. ""We didn't use a gait belt; we didn't use a mechanical lift. ""'I did not check the Patient information worksheet.' ""'I know we are a no lift company.' ""'I have used the lift in the past.' ..."" -- 5. Upon request, the facility provided a copy of the policy titled ""Mechanical Lift"" (dated 03/10/10). According to this document, the purpose of the policy is ""(t)o move immobile or obese patients for whom manual transfer poses potential for staff or patient injury"". Review of the facility's employee handbook revealed, under the heading ""Safety Rules"" on page 38: ""1. Report all accidents immediately, no matter how minor, to your supervisor. Your supervisor is required to make a thorough investigation and to complete an Accident Investigation Report. You are required to complete an Employee Incident Report for on-the-job accidents. ""2. Utilize appropriate lifting techniques and body mechanics for all lifting, including patient / resident transfers. All lifting must be performed in accordance with location procedures. Utilize mechanical lifting equipment where appropriate. ..."" -- 6. On the Patient Information Worksheet, Resident #147 was listed as requiring ""2 person / Mechanical Lift"". -- 7. In an interview on 12/22/10 at approximately 3:00 p.m., Employee #134 stated she did work on 09/02/10. She came back to work on 09/09/10 and recorded additional documentation in Resident #147's medical record, after she realized she had made an error regarding the time of the incident in her original note. Employee #134 stated a nurse aide did inform her that the resident complained of pain on the evening of 09/02/10. She assessed the resident's leg, and the resident did not appear to have any swelling, redness or tenderness to her leg during the assessment. She assisted the mobile imaging company during their x-ray of the resident's leg, and the resident did not appear to be in any pain at that time. -- 8. In an interview on 12/22/10 at approximately 3:30 p.m., Employee #141 stated his employment was terminated after this incident, but he was later asked to return to work. He reported he was not the aide assigned to Resident #146 on 09/02/10, but he did assist his co-worker (Employee #152) on that day. He verified they did not use a mechanical lift to transfer the resident from her wheelchair to her bed. He agreed he should have looked to see what type of assistance the resident needed for transferring before he assisted Employee #152, but he reiterated that he had his own assignments and had just agreed to help out a co-worker with a transfer on 09/02/10. -- 9. The assistant director of nursing (ADON - Employee #139) confirmed, during an interview on the afternoon of 12/22/10, the facility was a ""no lift company"". The ADON also confirmed that no incident / accident report was completed related to the events that took place on the evening of 09/02/10 involving Resident #147. -- 10. Although it could not be ascertained at what time the fracture occurred on 09/02/10, staff manually transferred Resident #147 on three (3) separate occasions on this date (from the wheelchair to the shower chair; from the shower chair back to the wheelchair on the evening; and from the wheelchair to the bed), contrary to the resident's comprehensive assessment, comprehensive care plan, and the Patient Information Sheet. The resident complained of leg pain during the second and third manual transfers, and the fracture was identified via x-ray in response to the resident's complaints of leg pain after the third manual transfer occurred. .",2014-04-01
11350,PARKERSBURG CENTER,515102,1716 GIHON ROAD,PARKERSBURG,WV,26101,2010-12-16,225,D,,,17LC11,". Based on record review, staff interview, and confidential staff interview, the facility failed to report an allegation of resident neglect by a nursing assistant to the appropriate State officials agencies when the identity of the alleged perpetrator was known. This was evident for one (1) of five (5) sampled residents. Resident identifier: #32. Facility census: 65. Findings include: a) Resident #32 Record review revealed Resident #32 received a head injury of unknown origin. Subsequently, this resident was transported to the emergency room for evaluation, then returned to the facility the same day. Record review revealed the facility reported this injury of unknown source to the appropriate State agencies, because the source of the injury was not observed by any person, it could not be explained by the resident (who was cognitively impaired due to a disease process), and the injury was suspicious because of the location and extent of the injury. Further record review revealed a licensed practical nurse (LPN - Employee #32) completed an incident report on the date and time of the discovery of the injury and documented an allegation that a nursing assistant caused the injury during turning and failed to notify the nurse of what she had done. -- Interview with the administrator, director of nursing, and the licensed social worker, on 12/14/10 at 3:00 p.m., revealed their belief that it would have been physically impossible for Resident #32's head to hit the bedside stand while being turned; they reported the aides ""speculated"" about what might have happened, and a former employee (Employee #84, a nursing assistant who was terminated last week) and other staff who were working the evening of the incident, when interviewed, admitted having no knowledge of how the injury happened. Subsequently, the administrator felt the allegation was hearsay, and the facility did not substantiate abuse or neglect in their investigation of the incident. -- Interview with Employee #32, on 12/14/10 at 3:25 p.m., revealed that the identity of Employee #84, who allegedly caused a head injury to Resident #32, was told to her and she included this allegation on the incident report but without writing the names of the alleged perpetrator or the reporter of this information. -- In an interview, another LPN (Employee #58) confirmed that she, too, was told of the allegation at the same time as Employee #32, that Employee #84 had allegedly caused the head injury while turning the resident but did not tell the nurse what she did. -- A confidential interview with member of the facility's nursing staff, on 12/15/10 at 12:25 p.m., revealed she heard Employee #84 admit to having injured Resident #32 while turning the resident alone, striking the resident's head against the overbed table, but was afraid to tell the nurse. -- During an interview with the administrator on 12/14/10 at 5:00 p.m., she acknowledged the allegation made against Employee #84 should have been reported to the Nurse Aide Abuse Registry, even though the facility did not substantiate abuse or neglect in their internal investigation. .",2014-04-01
11351,PARKERSBURG CENTER,515102,1716 GIHON ROAD,PARKERSBURG,WV,26101,2010-12-16,281,D,,,17LC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to follow physician's orders to perform monthly laboratory testing for one (1) of five (5) sampled residents. One (1) resident in the sample did not receive a monthly complete blood count (CBC) per physician's orders, as evidenced by one (1) CBC lab test omission in March 2010. A CBC drawn a month after the omitted lab test, in April 2010, revealed abnormal findings resulting in the resident's hospitalization Resident identifier: #67. Facility census: 65. Findings include: a) Resident #67 Record review revealed Resident #67 was diagnosed with [REDACTED]. A hospice encounter occurred in September 2009 but was declined by the family. Review of a facility's Encounter Sheet, dated 12/10/09, revealed the physician was to be consulted regarding increasing the [MEDICATION NAME] dosage, as this resident with multiple contractures and ""pain expressed (symbol for with) even slightest movement"". -- Record review revealed Resident #67's physician orders included orders for a basic metabolic profile (BMP) every three (3) months and CBC every month. Review of physicians orders effective from 03/01/10 through 03/31/10 revealed both the BMP and the CBC were both due on 03/10/10 and all CBCs were to be sent to Hospital #1. The BMP, requested and completed on 03/19/10 by the contracted lab service at Hospital #2, yielded results similar to the previous quarterly BMPs; however, there was no evidence to reflect the monthly CBC was requested and/or completed in March 2010. A CBC, requested and completed by the contracted lab service at Hospital #2 on 04/23/10, contained the following abnormal laboratory results: - WBC (white blood cell count) 1.2 (normal reference range 4.9 - 10.8); - RBC (red blood cell count) 1.98 (normal reference range 4.20 - 5.4); - HGB (hemoglobin) 5.9 (normal reference range 12.0 - 16.0); - HCT (Hematocrit) 18.3 (normal reference range 36 - 48%); and - PLT (Platelet) 44 (normal reference range 140 - 440). Review of past lab results revealed Resident #67's monthly WBC ranged from 5.8 in October 2009 to 6.4 on 02/22/10. The hemoglobin ranged from 9.2 in October 2009 to 8.6 on 02/22/10. The hematocrit ranged from 29.0 in October 2009 to 27.7 on 02/22/10. The platelets ranged from 188 in October 2009 to 222 on 02/22/10. -- Review of the interdisciplinary progress notes for 04/23/10 at 10:45 p.m. revealed Resident #67 was admitted to the hospital with [REDACTED]. Review of the interdisciplinary progress notes for 04/30/10 at 1:00 p.m. revealed the resident's medical power of attorney representative (MPOA) stated he had found placement for this resident at another facility, which had a private room the resident needed, and she would be transferred there following the hospital discharge. -- Interview with the administrator, on the early afternoon of 12/16/10, revealed a CBC report could not be located from either of the two (2) hospitals for March 2010.",2014-04-01
11352,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26505,2009-08-21,279,D,,,I2SV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, the facility failed to develop care plans, for one (1) of thirteen (13) sampled residents and one (1) resident of random opportunity, to reflect each resident's needs and the services being furnished to attain or maintain the resident's highest practicable physical well-being. One (1) resident had a physician's orders [REDACTED]. Another resident had sustained an injury when she spilled hot chocolate on herself, and no mention of this was made on the care plan in order to prevent another such incident. Resident identifiers: #8 and #13. Facility census: 54. Findings include: a) Resident #8 During a random tour of the facility on 08/18/09 at 2:00 p.m., observation found Resident #8 in her bed with side rails up on both sides. Review of the resident's medical record disclosed that, although the resident did have a physician's orders [REDACTED]. b) Resident #13 A review of the accident / incident reports and nursing notes found, on 06/08/09, Resident #13 ""fell asleep before breakfast in dining room with hot chocolate in her hand and spilled hot chocolate in her lap."" The resident's upper and inner thighs were red, with [MEDICATION NAME][MEDICAL CONDITION] the resident's upper inner bilateral thighs. When interviewed on 08/19/09 at 10:00 a.m., the resident related she was not sure whether she fell asleep or her fingers / hands were not good at holding things as well as before, and she was not sure exactly how the incident happened. She did not think the staff was doing anything differently since the incident occurred related to how she received hot liquids. A review of the resident's current care plan failed to find anything addressing how to promote resident safety with respect to drinking hot liquids without becoming burned. .",2014-04-01
11353,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26505,2009-08-21,309,E,,,I2SV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for three (3) of thirteen (13) sampled residents and three (3) residents of random opportunity. One (1) resident was hospitalized with a toxic level of medication, and no follow-up labs were completed after the resident's return to the facility. Five (5) residents were observed with side rails up and had no physician's orders for the use of side rails and no mention of their use in the plan of care. Resident identifiers: #40, #43, #15, #52, #30, and #41. Facility census: 54. Findings include: a) Resident #40 The medical record of Resident #40, when reviewed on 08/17/09, disclosed the resident was admitted to the facility on [DATE] from Health South following a [MEDICAL CONDITION] hip. At the time of admission, the resident was receiving the medication [MEDICATION NAME] 0.25 mg every day for the [DIAGNOSES REDACTED]. On 07/12/09, the resident was noted in nursing notes to be nauseous and having an episode of vomiting. The resident's son insisted she be transferred to the emergency room , from which she was admitted to the hospital with [REDACTED]. The resident returned to the facility on a decreased dose of [MEDICATION NAME] (0.0625 mg) and a potassium supplement on 07/20/09. A document entitled ""Physician's Orders"", received from the hospital, displayed an order which stated: ""Dig ([MEDICATION NAME]) level next week at The Madison."" The hospital discharge summary referenced above stated, ""Check her [MEDICATION NAME] level within one week and then do it every month thereafter until she is stable and then she can do it once or twice per year."" Further review of the record, on 08/17/09, divulged no evidence that a [MEDICATION NAME] level had been obtained since the resident's return to the facility. The facility's director of nurses (DON), when interviewed on 08/18/09 related to this finding, stated the resident's attending physician had not ordered a [MEDICATION NAME] level when the resident returned or at any time since she returned. The DON further stated it was not facility practice to carry out orders from a physician who had cared for the resident during hospitalization unless the attending physician concurred. A confidential interview with two (2) facility nurses related to this finding, on the afternoon of 08/18/09, disclosed that both nurses were not comfortable with no recheck of the resident's [MEDICATION NAME] level, and both felt the attending physician should have been questioned specifically about an order for [REDACTED]. The resident's physician was contacted on the afternoon of 08/18/09, and an order was received to obtain a [MEDICATION NAME] level for this resident. b) Resident #43 During a random tour of the facility by two (2) surveyors on 08/18/09 beginning at 2:00 p.m., observation found Resident #43 in bed with side rails up on both sides of the bed. The medical record of this resident, when reviewed, disclosed no physician's order for side rails in the up position, and no mention of the use of side rails was made in the plan of care for this resident. c) Resident #15 During a random tour of the facility by two (2) surveyors on 08/18/09 beginning at 2:00 p.m., observation found Resident #15 in bed with side rails up on both sides of the bed. The medical record of this resident, when reviewed, disclosed no physician's order for side rails in the up position, and no mention of the use of side rails was made in the plan of care for this resident. d) Resident #52 During a random tour of the facility by two (2) surveyors on 08/18/09 beginning at 2:00 p.m., observation found Resident #52 in bed with side rails up on both sides of the bed. The medical record of this resident disclosed that, although the resident had a pre-written document on his record with ""Side rails up when in bed"" checked, the document was signed only by a facility nurse; the resident's physician had not signed the order. When reviewed, no mention of the use of side rails was made in the plan of care for this resident. e) When interviewed on 08/18/09 at 2:45 p.m., the assistant director of nurses stated all residents who were using side rails in the up position should have a current physician's order. f) Resident #30 During a random tour of the facility by two (2) surveyors on 08/18/09 beginning at 2:00 p.m., observation found the resident lying in bed with bilateral half side rails up. The resident's bed was in a low position, and there were safety mats on the floor. Review of the August 2009 physician's orders found the resident was to use half side rails for ""turning and positioning"". A review of the side rail assessment, dated 04/11/08 and revised on 11/04/08, 12/11/08, 02/10/09, 03/10/09, 04/08/09, 05/01/09, 06/06/09, 07/12/09, and 08/12/09, found each time the assessment was updated, there were no changes with a only comment indicating the resident used half rails as an enabler. There were no comments on the side rail assessment as to how the assessment was completed or whether the resident was observed in order to complete the assessment. Documentation on the front of the assessment stated, ""The resident had intermittent confusion, was able to get out of bed safely with assistance, had a history of [REDACTED]."" A fall risk assessment, dated 07/26/09, indicated the resident was rated a ""10"" or at high risk for falls. The mini mental status exam, dated 11/02/08, indicated the resident had severe dementia. The minimum data set assessment, dated 08/06/09, indicated the resident has fallen within the last thirty (30) days, used the side rails for bed mobility / transfer, required extensive assistance of one (1) for bed mobility, and was totally dependent on one (1) person for transfer. The most recent care plan, dated 05/30/09, indicated the resident was at risk ""for falls related to history of falls, lack of safety awareness related to dementia"", but it did not address the use of side rails in the care plan. A confidential staff interview, on the afternoon of 08/18/09, found the resident was unable to use the side rails and often resisted care by staff. When questioned regarding the resident's ability to hold onto the side rails during care, the staff member indicated the resident only did this occasionally. During an interview with the director of nursing on 08/19/09 at 2:30 p.m., she indicated the resident's ability to use the side rails varied. g) Resident #41 During a random tour of the facility by two (2) surveyors on 08/18/09 beginning at 2:00 p.m., observation found the resident lying in bed with bilateral half side rails up. The resident's bed was in a medium height position. A side rail assessment, completed on 05/11/09 and revised on 06/07/09, 07/12/09, and 08/12/09, reflected the resident did not use side rails. The 06/12/09 minimum data set assessment indicated the resident used side rails for mobility / transfer, with the self-performance of bed mobility and transfers requiring the extensive assistance of one (1) staff member, and a fall having occurred during the previous thirty (30) days. Review of the physician's orders for August 2009 failed to find physician's orders for the side rails. The current care plan, dated 06/30/09, did not address the use of side rails for the resident. During an interview with the administrator and the DON on 08/19/09 at 2:30 p.m., the DON indicated this resident was not supposed to have side rails in use. .",2014-04-01
11354,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26505,2009-08-21,159,D,,,I2SV11,"Based on record review and staff interview, the facility disclosed information regarding a resident's personal funds account to individuals who did not have the legal authority to receive this information. This was evident for two (2) of four (4) residents whose personal funds were reviewed. Residents #7 and #57. Facility census: 54. Findings include: a) Residents #7 and #57 A review of the financial information for Residents #7 and #57 found there was no authorization for anyone to handle financial matters for these residents. A review of the personal funds records with the business office manager, on 08/20/09 at 10:00 a.m., found quarterly financial statements were sent to unauthorized representatives for both residents. .",2014-04-01
11355,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26505,2009-08-21,371,F,,,I2SV11,"Based on observation and staff interview, the facility failed to store foods under sanitary conditions. Cold temperatures for milk at 41 degrees F or less were not maintained. Milk from the milk machine temperatures were observed at 42 -50 degrees Fahrenheit (F). This had the potential to affect all residents who drank milk. Facility census: 54. Findings include: a) Observation of preparation of the noon meal, in the dietary department on 08/19/09, found milk in small glasses on a tray in the kitchen. A request was made for one (1) of the cooks (Employee #3) to take the milk temperatures. The first temperature read 50 degrees F, and the second read 45 degrees F. A request was made to take the temperature of milk just after it came from the milk dispenser; this was 45 degrees F, while the external thermometer on the dispenser read 42 degrees F. The temperature of milk dispensed from the machine was measured another thermometer, which read 43 degrees F, while the internal thermometer inside the dispenser read 30 degrees F. Employee #3 and the dietary supervisor were both present. A request was made to review the temperature logs for the milk dispenser. The employee reported she recorded temperatures for both the cooler and the milk dispenser, and it could not be determined whether the temperature logs were for the cooler or the milk dispenser. The temperatures varied from 38 degrees F to 40 degrees F, according to the log, and were listed as measuring the temperature of the refrigerator. .",2014-04-01
11356,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-08-26,323,G,,,3L9811,". Based on observations, the facility failed to ensure the resident environment remained as free of accident hazards as possible. A treatment cart was found unlocked and unattended on the Blue Ridge hall in the presence of mobile residents. The cart contained items that had the potential to be harmful if ingested or used in a manner other than they were intended to be used. All mobile residents on the Blue Ridge hall had the potential to be affected. Facility census: 114. Findings include: a) Treatment cart - unlocked and unattended During random observations of the facility on 08/24/10 at 7:30 a.m., the treatment cart of Blue Ridge was found sitting outside of the Blue Ridge nurses' station. The cart was not locked, and no staff was in line of sight of the cart. The cart contained a variety of treatment supplies, i.e., a container of Greer's Goo (composed of nystatin (Mycostatin) powder 4 million U, hydrocortisone powder 1.2 g, and zinc oxide paste), Nystop (an antifungal), and a large bottle of 100% Acetone. There would be a potential for adverse reactions should a resident who was sensitive / allergic to Mycostatin or Nystop have contact with the Greer's Goo and / or Nystop. Acetone (http://www.drugs.com/enc/acetone-poisoning.html) has the potential to cause cardiovascular problems (hypotension), gastrointestinal problems (nausea, abdominal pain, vomiting), the nervous system may be affected (seem as though drunk, coma), as might the respiratory system .",2014-04-01
11357,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-09-10,323,G,,,9G3Y12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on medical record review, review of facility records, staff interview, and family interview, the facility failed to provide adequate supervision and/or appropriate assistive devices, based on a comprehensive assessment of the resident, to promote the safety of one (1) of three (3) residents whose closed records were reviewed. Resident #114 sustained a total of five (5) falls between his admission date of [DATE] and [DATE], when the resident expired at the facility. A fall from the bed on [DATE] resulted in a fractured nasal bone. A fall from the bed on [DATE] resulted in a complaint of shoulder and back pain; the resident was transported to the hospital, but x-rays were negative for fractures. On [DATE], the resident had three (3) falls from a wheelchair with no injury noted. The last fall occurred on [DATE], when the resident was found on the floor by the pharmacy delivery man at 8:30 p.m. that night, having fallen out of a reclined geri-chair located at the nurses' station. The resident sustained [REDACTED]. Medical record review and an interview with the rehabilitative therapy program manager disclosed this resident had been identified as being at risk for falls upon his admission to the facility, and staff was aware the resident was constantly attempting to get out of chairs and bed. There was no evidence in his medical record to reflect the use of the reclining geri-chair with this resident had been evaluated by physical therapy, ordered by the physician, or addressed in his care plan. Interviews with nursing staff present on [DATE] confirmed the resident had been left unsupervised in a reclining geri-chair for an unknown length of time prior to his fall. Resident identifier: #114. Facility census: 113. Findings include: a) Resident #114 1. Medical record review disclosed this [AGE] year old resident was admitted to the facility from the hospital on [DATE] for skilled services and rehabilitative therapy with the possibility of returning home with family. Prior to the hospital admission, he had been living at home with his family. Review of the hospital discharge summary revealed the resident had [DIAGNOSES REDACTED]. The resident was admitted to the hospital and was treated with antibiotics for pneumonia or urosepsis. The hospital discharge summary also noted the resident had been confused, agitated, attempting to get out of bed, and occasionally combative with staff. -- 2. Review of the resident's nursing home admission record revealed Resident #114 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his nursing home admission orders [REDACTED]. -- 3. Review of the facility's incident / accident reports revealed the following: - On [DATE] at 9:30 p.m., Resident #114 was found lying on the floor mat beside the bed with his nose bleeding. The report described the injury as ""Nose Deformity /c (with) Bruising & Nose bleed"". First aid was provided for the nose bleed, neuro checks were initiated because this was an unwitnessed fall, and the physician, when notified, ordered a facial x-ray. The x-ray, completed on [DATE], revealed a fracture of nasal bone. Elsewhere on the report, the author noted, under the heading ""Protective Devices"" that a low bed with floor mats had been ordered and were in use at the time of the incident to prevent injury. - On [DATE] at 7:10 p.m., ""Called into Rm (room) by Dayshift Nurse (sic) found Resident laying on floor on (R) (right) side c/o (complained of) (L) (left) shoulder & Low Back Pain (in room) laying on landing strip."" There was no discussion on the incident report as to whether this was an unwitnessed fall. The resident was sent to the hospital for evaluation, where x-rays and a CT scan were negative. Instructions from the hospital emergency room included fall precautions. - On [DATE] at 9:15 a.m., ""Called to hall by other nurse, found resident lying in floor in front of w/c (wheelchair)."" Neuro checks were initiated because this was an unwitnessed fall. The author indicated there were no apparent injuries. - On [DATE] at 9:00 p.m., ""Resident scooted to edge of w/c (wheelchair) & then sat in floor, assessed for injury & placed back into w/c, resident stated 'I'm gonna do it again"", then proceeded to scoot to edge of w/c & sit back on the floor again, attempted to redirect & explain risk of injury /s (without) success. The report indicated there was no injury noted from the two (2) falls from the wheelchair and the resident was placed in bed after the second fall. - On [DATE] at 8:30 p.m., ""Was called to nurses station by pharmacy to find (resident's name) on his right side on floor next to chair. Upon assessment found his forehead bleeding. Took vitals & paged (nurse's name) to unit."" Under the heading ""Description of Injury"" was written ""2 abrasions to forehead / top of head & 1 by (R) (right) eye. Resident stated head, neck, (R) shoulder & (R) hip hurt."" Under the heading ""Protective Devices"" the author noted a reclined geri-chair was in use at the time of the fall due to ""freq. (frequent) falls"". Neuro checks were initiated because this was an unwitnessed fall, and the resident was transported to the local hospital emergency department for evaluation. A nursing note, dated [DATE] at 22:00 (10:00 p.m.), revealed the resident was found in floor by the pharmacy delivery man; he notified the floor nurse, who called supervisor. This note also stated the resident's injuries were assessed and he was transferred to the hospital. A nursing note, dated [DATE] at 05:13 a.m., revealed the hospital called the facility to notify staff the resident had fractures of C1 and C2 vertebrae and the hospital was sending the resident to another hospital to see a neurosurgeon. Another nursing note, dated [DATE] at 10:02 a.m., revealed the resident had arrived back at the facility. The new order from the hospital was to keep the Miami collar on the resident's neck at all times. -- 4. During an interview on [DATE] at 7:30 p.m., a family member reported Resident #114 was very agitated with the cervical collar and continuously attempted to remove it. The family member also reported that a meeting was held at the facility with management staff, at which time the falls and the importance of keeping the cervical collar in place were discussed. The family member reported staff informed him/her this facility had a ""Right to Fall Policy""; however, when the family member requested a copy of this policy, it was not provided. -- 5. Interviews were conducted with staff on duty on [DATE] as follows: On [DATE] at 9:30 a.m., an interview was conducted with a nursing assistant (Employee #24). Employee #24 reported she had assisted putting the resident in the geri-chair. She stated she could not remember the time they put him in the chair. She stated he was put in the reclining geri-chair to be close to the nurses' station for close observation. - On [DATE] at 10:45 a.m., an interview was conducted with the therapy program manager (Employee #144) who had worked with this resident and familiar with the resident's therapy plan. Employee #144 reported the resident was constantly attempting to get up and moving constantly. Resident #114 had been evaluated for the use of a wheelchair with anti-tippers for transport and while in therapy, but the use of a reclining geri-chair had not been recommended by physical therapy. - On [DATE] at 11:30 a.m., an interview was conducted with the RN manager of the unit on which Resident #114 resided (Employee #98). During this interview, Employee #98 confirmed Resident #114 had been placed in a reclining geri-chair on that weekend, and there was no physician order for [REDACTED]. The RN manager stated she did not know who was responsible for putting the resident in the geri-chair. - On [DATE] at 2:50 p.m., a telephone interview was conducted with Employee #103, the registered nurse (RN) who worked from 7:00 a.m. to 7:00 p.m. on [DATE] and was responsible for Resident #114 ' s care on that day. (Review of the resident's medical record disclosed a nursing note dated [DATE] at 22:00 (10:00 p.m.), in which this RN documented the accident and a resident assessment and signed off as the nurse supervisor.) During the interview, Employee #103 reported she did not know who put the resident into the geri-chair or at what time he was placed there on [DATE]. She stated the chair was reclined and no staff was in the area of the nurses' station at the time of the fall. She further reported she was assigned to another area and did not know much about the accident. - On [DATE] at 2:55 p.m., a telephone interview was conducted with Employee #2, an RN who worked 7:00 p.m. to 7:00 a.m. on [DATE] and was working in the area at the time of the incident. Employee #2 stated the resident was in the reclining geri-chair when she arrived at the facility at 7:00 p.m. She also stated she was giving medications to other residents on the 800 hall and was out of sight of Resident #114. She stated the nursing assistants were busy helping other residents in their rooms and there was no one at the nurses' station when Resident #114 fell . She stated she learned of the resident's fall when the pharmacy delivery man came and told her there was a man on the floor. - On [DATE] at 9:15 a.m., an interview was conducted with Employee #27, the nursing assistant who was responsible for Resident #114's care during the 7:00 a.m. to 3:00 p.m. (,[DATE]) shift on [DATE]. Employee #27 confirmed she was assigned to this resident on that day, and she acknowledged she was probably the person who put the resident in the geri-chair, but she could not recall at what time this occurred. Employee #27 stated Resident #114 was constantly moving all the time (sliding out of bed and scooting off of chairs), that a geri-chair in a reclining position was the only chair he might not fall out of, and that he was placed at the nurses' station for closer observation. According to Employee #27, when she left at the end of her shift at 3:00 p.m., the resident was still in the geri-chair. -- 6. Review of Resident #114's comprehensive care plan found the following problem statement, with an initiated date of [DATE] and reviewed / updated on [DATE] an [DATE]: ""Resident is at risk for falls: (sic) cognitive loss, lack of safety awareness."" The goal associated with this problem statement was: ""Resident will have < (symbol for 'less than') 2 falls per day x 90 days."" The interventions intended to assist the resident in achieving this goal were: ""Resident likes to lay (sic) in the floor. He will often lower himself to floor and sometimes will prop his feet up on objects. Medication evaluation as needed. Therapy / Rehab - PR Treatment 5x per week. Use a mechanical lift (sic) two person for transfer. Bed in low position with right side against wall and landing strip on the left side of the bed. Provide verbal cues for safety and sequencing when needed. Provide resident / caregiver education for safe techniques. Place call light within reach at all times. Maintain a clutter-free environment in the resident's room and consistant (sic) furniture arrangement. When resident is in bed, place all necessary personal items within reach. "" There was no mention of an intervention to place the resident in a reclining geri-chair and no mention of an intervention to locate the resident at the nurses' station for close observation. -- 7. Resident #114 sustained a total of five (5) falls, two (2) of which resulted in fractures. These falls occurred between his admission date of [DATE] and [DATE], when the resident expired at the facility. The last fall occurred on [DATE], when the resident was put in a reclining geri-chair at an unknown time during the ,[DATE] shift. According to the nursing assistant responsible for the resident's care on [DATE], the resident was still in the reclining geri-chair at the nursing station when she left her shift at 3:00 p.m. According to an interview with the RN who came on for her shift at 7:00 p.m., the resident was in the reclining geri-chair at the nurses' station when she arrived at work. The resident was found on the floor by the pharmacy delivery man at 8:30 p.m. that night. Medical record review and an interview with the rehabilitative therapy program manager disclosed this resident had been identified as being at risk for falls upon his admission to the facility, and staff was aware the resident was constantly attempting to get out of chairs and bed. Interviews with nursing staff present on [DATE] confirmed the resident had been left unsupervised in a reclining geri-chair prior to his fall; the use of the geri-chair with this resident had not been evaluated by physical therapy or ordered by the physician. --- Part II -- Based on medical record review, observation, resident interview, and staff interview, the facility failed to assure assistance devices to promote safety were applied as ordered by the physician for one (1) of three (3) residents reviewed. Resident #85 had a physician order, dated [DATE], for hipsters at all times except for bathing, related to falls. Observation and resident interview, on [DATE] at 10:45 a.m., found the resident dressed herself and did not have on the hipsters. Resident identifier: #85. Facility census: 113. Findings include: a) Resident #85 Medical record review, on [DATE], disclosed Resident #85 had a physician's order, dated [DATE], for hipsters to be applied at all times except for bathing due to falls. Observation of and interview with the resident, on [DATE] at 10:45 a.m., found she was not wearing the hipsters. The resident stated she had dressed herself in the morning and did not put them on. The resident also stated she could not remember the last time she had put them on. The resident was ambulating in her room during this observation, and she acknowledged having had falls in the past. Medical record review found the resident had a fall on [DATE]. This practice was brought to the attention of the interim director of nursing (DON - Employee #145) in the resident's room on [DATE] at 11:20 a.m., where it was confirmed the resident was not wearing hipsters. The DON also confirmed the nursing assistant who was assigned to this resident was responsible for ensuring the resident put the hipsters on as ordered to prevent injury due to falls. .",2014-04-01
11358,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-12-09,323,G,,,777711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on medical record review, review of facility records, staff interview, and family interview, the facility failed to provide adequate supervision and/or appropriate assistive devices, based on a comprehensive assessment of the resident, to promote the safety of one (1) of three (3) residents whose closed records were reviewed. Resident #114 sustained a total of five (5) falls between his admission date of [DATE] and [DATE], when the resident expired at the facility. A fall from the bed on [DATE] resulted in a fractured nasal bone. A fall from the bed on [DATE] resulted in a complaint of shoulder and back pain; the resident was transported to the hospital, but x-rays were negative for fractures. On [DATE], the resident had three (3) falls from a wheelchair with no injury noted. The last fall occurred on [DATE], when the resident was found on the floor by the pharmacy delivery man at 8:30 p.m. that night, having fallen out of a reclined geri-chair located at the nurses' station. The resident sustained [REDACTED]. Medical record review and an interview with the rehabilitative therapy program manager disclosed this resident had been identified as being at risk for falls upon his admission to the facility, and staff was aware the resident was constantly attempting to get out of chairs and bed. There was no evidence in his medical record to reflect the use of the reclining geri-chair with this resident had been evaluated by physical therapy, ordered by the physician, or addressed in his care plan. Interviews with nursing staff present on [DATE] confirmed the resident had been left unsupervised in a reclining geri-chair for an unknown length of time prior to his fall. Resident identifier: #114. Facility census: 113. Findings include: a) Resident #114 1. Medical record review disclosed this [AGE] year old resident was admitted to the facility from the hospital on [DATE] for skilled services and rehabilitative therapy with the possibility of returning home with family. Prior to the hospital admission, he had been living at home with his family. Review of the hospital discharge summary revealed the resident had [DIAGNOSES REDACTED]. The resident was admitted to the hospital and was treated with antibiotics for pneumonia or urosepsis. The hospital discharge summary also noted the resident had been confused, agitated, attempting to get out of bed, and occasionally combative with staff. -- 2. Review of the resident's nursing home admission record revealed Resident #114 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his nursing home admission orders [REDACTED]. -- 3. Review of the facility's incident / accident reports revealed the following: - On [DATE] at 9:30 p.m., Resident #114 was found lying on the floor mat beside the bed with his nose bleeding. The report described the injury as ""Nose Deformity /c (with) Bruising & Nose bleed"". First aid was provided for the nose bleed, neuro checks were initiated because this was an unwitnessed fall, and the physician, when notified, ordered a facial x-ray. The x-ray, completed on [DATE], revealed a fracture of nasal bone. Elsewhere on the report, the author noted, under the heading ""Protective Devices"" that a low bed with floor mats had been ordered and were in use at the time of the incident to prevent injury. - On [DATE] at 7:10 p.m., ""Called into Rm (room) by Dayshift Nurse (sic) found Resident laying on floor on (R) (right) side c/o (complained of) (L) (left) shoulder & Low Back Pain (in room) laying on landing strip."" There was no discussion on the incident report as to whether this was an unwitnessed fall. The resident was sent to the hospital for evaluation, where x-rays and a CT scan were negative. Instructions from the hospital emergency room included fall precautions. - On [DATE] at 9:15 a.m., ""Called to hall by other nurse, found resident lying in floor in front of w/c (wheelchair)."" Neuro checks were initiated because this was an unwitnessed fall. The author indicated there were no apparent injuries. - On [DATE] at 9:00 p.m., ""Resident scooted to edge of w/c (wheelchair) & then sat in floor, assessed for injury & placed back into w/c, resident stated 'I'm gonna do it again"", then proceeded to scoot to edge of w/c & sit back on the floor again, attempted to redirect & explain risk of injury /s (without) success. The report indicated there was no injury noted from the two (2) falls from the wheelchair and the resident was placed in bed after the second fall. - On [DATE] at 8:30 p.m., ""Was called to nurses station by pharmacy to find (resident's name) on his right side on floor next to chair. Upon assessment found his forehead bleeding. Took vitals & paged (nurse's name) to unit."" Under the heading ""Description of Injury"" was written ""2 abrasions to forehead / top of head & 1 by (R) (right) eye. Resident stated head, neck, (R) shoulder & (R) hip hurt."" Under the heading ""Protective Devices"" the author noted a reclined geri-chair was in use at the time of the fall due to ""freq. (frequent) falls"". Neuro checks were initiated because this was an unwitnessed fall, and the resident was transported to the local hospital emergency department for evaluation. A nursing note, dated [DATE] at 22:00 (10:00 p.m.), revealed the resident was found in floor by the pharmacy delivery man; he notified the floor nurse, who called supervisor. This note also stated the resident's injuries were assessed and he was transferred to the hospital. A nursing note, dated [DATE] at 05:13 a.m., revealed the hospital called the facility to notify staff the resident had fractures of C1 and C2 vertebrae and the hospital was sending the resident to another hospital to see a neurosurgeon. Another nursing note, dated [DATE] at 10:02 a.m., revealed the resident had arrived back at the facility. The new order from the hospital was to keep the Miami collar on the resident's neck at all times. -- 4. During an interview on [DATE] at 7:30 p.m., a family member reported Resident #114 was very agitated with the cervical collar and continuously attempted to remove it. The family member also reported that a meeting was held at the facility with management staff, at which time the falls and the importance of keeping the cervical collar in place were discussed. The family member reported staff informed him/her this facility had a ""Right to Fall Policy""; however, when the family member requested a copy of this policy, it was not provided. -- 5. Interviews were conducted with staff on duty on [DATE] as follows: On [DATE] at 9:30 a.m., an interview was conducted with a nursing assistant (Employee #24). Employee #24 reported she had assisted putting the resident in the geri-chair. She stated she could not remember the time they put him in the chair. She stated he was put in the reclining geri-chair to be close to the nurses' station for close observation. - On [DATE] at 10:45 a.m., an interview was conducted with the therapy program manager (Employee #144) who had worked with this resident and familiar with the resident's therapy plan. Employee #144 reported the resident was constantly attempting to get up and moving constantly. Resident #114 had been evaluated for the use of a wheelchair with anti-tippers for transport and while in therapy, but the use of a reclining geri-chair had not been recommended by physical therapy. - On [DATE] at 11:30 a.m., an interview was conducted with the RN manager of the unit on which Resident #114 resided (Employee #98). During this interview, Employee #98 confirmed Resident #114 had been placed in a reclining geri-chair on that weekend, and there was no physician order for [REDACTED]. The RN manager stated she did not know who was responsible for putting the resident in the geri-chair. - On [DATE] at 2:50 p.m., a telephone interview was conducted with Employee #103, the registered nurse (RN) who worked from 7:00 a.m. to 7:00 p.m. on [DATE] and was responsible for Resident #114 ' s care on that day. (Review of the resident's medical record disclosed a nursing note dated [DATE] at 22:00 (10:00 p.m.), in which this RN documented the accident and a resident assessment and signed off as the nurse supervisor.) During the interview, Employee #103 reported she did not know who put the resident into the geri-chair or at what time he was placed there on [DATE]. She stated the chair was reclined and no staff was in the area of the nurses' station at the time of the fall. She further reported she was assigned to another area and did not know much about the accident. - On [DATE] at 2:55 p.m., a telephone interview was conducted with Employee #2, an RN who worked 7:00 p.m. to 7:00 a.m. on [DATE] and was working in the area at the time of the incident. Employee #2 stated the resident was in the reclining geri-chair when she arrived at the facility at 7:00 p.m. She also stated she was giving medications to other residents on the 800 hall and was out of sight of Resident #114. She stated the nursing assistants were busy helping other residents in their rooms and there was no one at the nurses' station when Resident #114 fell . She stated she learned of the resident's fall when the pharmacy delivery man came and told her there was a man on the floor. - On [DATE] at 9:15 a.m., an interview was conducted with Employee #27, the nursing assistant who was responsible for Resident #114's care during the 7:00 a.m. to 3:00 p.m. (,[DATE]) shift on [DATE]. Employee #27 confirmed she was assigned to this resident on that day, and she acknowledged she was probably the person who put the resident in the geri-chair, but she could not recall at what time this occurred. Employee #27 stated Resident #114 was constantly moving all the time (sliding out of bed and scooting off of chairs), that a geri-chair in a reclining position was the only chair he might not fall out of, and that he was placed at the nurses' station for closer observation. According to Employee #27, when she left at the end of her shift at 3:00 p.m., the resident was still in the geri-chair. -- 6. Review of Resident #114's comprehensive care plan found the following problem statement, with an initiated date of [DATE] and reviewed / updated on [DATE] an [DATE]: ""Resident is at risk for falls: (sic) cognitive loss, lack of safety awareness."" The goal associated with this problem statement was: ""Resident will have < (symbol for 'less than') 2 falls per day x 90 days."" The interventions intended to assist the resident in achieving this goal were: ""Resident likes to lay (sic) in the floor. He will often lower himself to floor and sometimes will prop his feet up on objects. Medication evaluation as needed. Therapy / Rehab - PR Treatment 5x per week. Use a mechanical lift (sic) two person for transfer. Bed in low position with right side against wall and landing strip on the left side of the bed. Provide verbal cues for safety and sequencing when needed. Provide resident / caregiver education for safe techniques. Place call light within reach at all times. Maintain a clutter-free environment in the resident's room and consistant (sic) furniture arrangement. When resident is in bed, place all necessary personal items within reach. "" There was no mention of an intervention to place the resident in a reclining geri-chair and no mention of an intervention to locate the resident at the nurses' station for close observation. -- 7. Resident #114 sustained a total of five (5) falls, two (2) of which resulted in fractures. These falls occurred between his admission date of [DATE] and [DATE], when the resident expired at the facility. The last fall occurred on [DATE], when the resident was put in a reclining geri-chair at an unknown time during the ,[DATE] shift. According to the nursing assistant responsible for the resident's care on [DATE], the resident was still in the reclining geri-chair at the nursing station when she left her shift at 3:00 p.m. According to an interview with the RN who came on for her shift at 7:00 p.m., the resident was in the reclining geri-chair at the nurses' station when she arrived at work. The resident was found on the floor by the pharmacy delivery man at 8:30 p.m. that night. Medical record review and an interview with the rehabilitative therapy program manager disclosed this resident had been identified as being at risk for falls upon his admission to the facility, and staff was aware the resident was constantly attempting to get out of chairs and bed. Interviews with nursing staff present on [DATE] confirmed the resident had been left unsupervised in a reclining geri-chair prior to his fall; the use of the geri-chair with this resident had not been evaluated by physical therapy or ordered by the physician. --- Part II -- Based on medical record review, observation, resident interview, and staff interview, the facility failed to assure assistance devices to promote safety were applied as ordered by the physician for one (1) of three (3) residents reviewed. Resident #85 had a physician order, dated [DATE], for hipsters at all times except for bathing, related to falls. Observation and resident interview, on [DATE] at 10:45 a.m., found the resident dressed herself and did not have on the hipsters. Resident identifier: #85. Facility census: 113. Findings include: a) Resident #85 Medical record review, on [DATE], disclosed Resident #85 had a physician's order, dated [DATE], for hipsters to be applied at all times except for bathing due to falls. Observation of and interview with the resident, on [DATE] at 10:45 a.m., found she was not wearing the hipsters. The resident stated she had dressed herself in the morning and did not put them on. The resident also stated she could not remember the last time she had put them on. The resident was ambulating in her room during this observation, and she acknowledged having had falls in the past. Medical record review found the resident had a fall on [DATE]. This practice was brought to the attention of the interim director of nursing (DON - Employee #145) in the resident's room on [DATE] at 11:20 a.m., where it was confirmed the resident was not wearing hipsters. The DON also confirmed the nursing assistant who was assigned to this resident was responsible for ensuring the resident put the hipsters on as ordered to prevent injury due to falls.",2014-04-01
11359,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,250,D,,,GCMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and interview with a hospital social, the facility failed to provide medically-related social services for two (2) of thirty-two (32) Stage II sample residents. Resident #35 was sent out to the hospital for a behavioral evaluation on 09/24/10. The resident had several behavioral incidents for which there was no evidence of assessment to determine the causative factors and no planned medically-related social service interventions to address the behaviors. Resident #31 missed a medical appointment, because the facility did not remind him so that he was prepared in advance. Resident identifiers: #35 and #31. Facility census: 83. Findings include: a) Resident #35 Medical record review revealed this resident was admitted to the facility on [DATE] for a long-term stay. According to the facility's interdisciplinary discharge plan dated 2/09/10, the plan for discharge on admission was for ""definite long-term stay"". He was admitted with [DIAGNOSES REDACTED]. Review of the medical record also revealed the resident's vision was poor, and his hearing was so poor he used a communication board to communicate his needs. Medical record review revealed the resident resided at the facility from 02/08/10 until 07/03/10 with no inappropriate behaviors. According to the medical record, on 07/03/10, the resident smashed the light in his room with his trapeze bar. On 07/26/10, he was witnessed hitting the wall with the trapeze bar. On 07/29/10, he slammed the bedside chair and water pitcher into the wall and hit the nurse. On 08/01/10, he was pounding on the wall with the trapeze bar. On 08/08/10, he made vulgar comments to a nursing assistant. On 08/16/10, he was found outside in the courtyard smoking. The cigarette was taken from him and he was told the facility is a non-smoking facility. On 08/17/10, he hit the wall with the trapeze bar. The medical record contained no evidence of efforts by the facility to identify of causative factors and/or interventions for any of the documented behavioral episodes. There was no evidence that staff considered the need for medically-related social services or services from an appropriate mental health professional to address this resident's behavioral issues. The facility did not initiate a care plan to address behaviors until 08/26/10, when the resident exhibited inappropriate sexual behaviors toward staff, and the intervention was to ""redirect resident"". No other behaviors were identified and/or addressed on the care plan. The care plan provided no methods for implementing this redirection. On 09/06/10, the resident was verbally sexually inappropriate with staff, and on 09/07/10, he bit a nursing assistant on the breast. There was no evidence of attempts at redirection. Staff just told this confused resident his behaviors were ""inappropriate"". Further review of the medical record revealed nursing documentation for 09/24/10 at 5:00 a.m., at which time the registered nurse (RN) supervisor (Employee #20) was notified Resident #35 was found on two (2) occasions the previous evening in a female resident's room exhibiting inappropriate sexual behaviors. Staff removed the resident from the female resident's room, but there was no evidence of any other intervention to reduce or prevent these behaviors. On 09/07/10, the resident was seen by his physician. The physician's progress notes on that date contained nothing relative to the resident's behaviors, and there was no evidence the physician had been made aware of the resident's behaviors. In addition, the physician made no recommendations or addressed any of the behaviors the resident had been exhibiting. During an interview on 12/09/10 at 2:21 p.m., the administrator confirmed there was no evidence the facility's social services had initiated a discharge plan related to Resident #35 being transferred to another facility, although the administrator confirmed the facility had started to work on discharging Resident #35 to a facility in Ohio prior to the resident being sent to the hospital on [DATE]. When the administrator was asked for social service notes, she stated, ""Yes, there should be some kind of discharge information started and written in the chart, but there is not, and I can't say why it's not there."" On 12/09/10 at 12:59 p.m., the social service department at the hospital was contacted and confirmed the facility had prearranged placement at another facility prior to Resident #35 being transferred to the hospital on [DATE]. The social service staff member confirmed the facility had said they could not take him back. At the time the resident was transferred to the hospital for an evaluation regarding his behaviors on 09/24/10, there was no evidence the facility had made any attempts to determine causal factors which may have contributed to the resident's behaviors, and no evidence of the provision of medically-related social services or services from an appropriate mental health professional to address these behaviors. b) Resident #31 On 12/02/10 at approximately 3:00 p.m., Resident #31 stated he had a medical appointment scheduled for today, but he did not go to this appointment. He said no one told him about the appointment and therefore he did not know he had to go. He said the ambulance attendants came to his room and he did not know why they were there. They informed him they were taking him to a local hospital for some medical test. He chose not to go with them, because according to him, he ""did not know anything about an appointment until the ambulance people came to (his) room."" The nurse aide (Employee #65) said she came to work at 7:30 a.m. on 12/02/10. She indicated no one had informed her Resident #31 had an appointment on 12/02/10. According to Employee #65, the night shift nurse aide had already made the bed, and the resident had his clothes on for the day. Employee #70 (a registered nurse) said the physician had told Resident #31, on 11/29/10, he had an appointment on 12/02/10. She went on to say things were chaotic on the morning of 12/02/10, and she had forgotten to remind Resident #31 of his appointment today. She agreed the resident the nursing staff should remind residents of their scheduled appointments on the day of the appointment. Resident #31 recently had a computed tomography (CT) scan where lesions and tumors were found on his liver. The appointment on12/02/10 was scheduled for further testing related to these issues. .",2014-04-01
11360,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,201,D,,,GCMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, family interview, and interview with the social worker at the hospital, the facility failed to attempt to meet the needs of one (1) of six (6) sampled residents prior to planning his discharge from the facility. Resident #35 was sent out to the hospital for a behavioral evaluation on 09/24/10. There was evidence the facility had no plans to readmit the resident after the evaluation. The resident had several behavioral incidents for which there was no evidence of assessment to determine the causal factors and no planned intervention to address the behaviors. Evidence revealed the facility had prearranged for the resident to be transferred to a local hospital then be transferred to another facility out of state. Resident identifier: #35. Facility census: 83. Findings include: a) Resident #35 Medical record review revealed this resident was admitted to the facility on [DATE] for a long-term stay. According to the facility's interdisciplinary discharge plan dated 2/09/10, the plan for discharge on admission was for ""definite long-term stay"". He was admitted with [DIAGNOSES REDACTED]. Review of the medical record also revealed the resident's vision was poor, and his hearing was so poor he used a communication board to communicate his needs. Medical record review revealed the resident resided at the facility from 02/08/10 until 07/03/10 with no inappropriate behaviors. According to the medical record, on 07/03/10, the resident smashed the light in his room with his trapeze bar. On 07/26/10, he was witnessed hitting the wall with the trapeze bar. On 07/29/10, he slammed the bedside chair and water pitcher into the wall and hit the nurse. On 08/01/10, he was pounding on the wall with the trapeze bar. On 08/08/10, he made vulgar comments to a nursing assistant. On 08/16/10, he was found outside in the courtyard smoking. The cigarette was taken from him and he was told the facility is a non-smoking facility. On 08/17/10, he hit the wall with the trapeze bar. The medical record contained no evidence of efforts by the facility to identify of causative factors and/or interventions for any of the documented behavioral episodes. There was no evidence that staff considered the need for medically-related social services or services from an appropriate mental health professional to address this resident's behavioral issues. The facility did not initiate a care plan to address behaviors until 08/26/10, when the resident exhibited inappropriate sexual behaviors toward staff, and the intervention was to ""redirect resident"". No other behaviors were identified and/or addressed on the care plan. The care plan provided no methods for implementing this redirection. On 09/06/10, the resident was verbally sexually inappropriate with staff, and on 09/07/10, he bit a nursing assistant on the breast. There was no evidence of attempts at redirection. Staff just told this confused resident his behaviors were ""inappropriate"". Further review of the medical record revealed nursing documentation for 09/24/10 at 5:00 a.m., at which time the registered nurse (RN) supervisor (Employee #20) was notified Resident #35 was found on two (2) occasions the previous evening in a female resident's room exhibiting inappropriate sexual behaviors. Staff removed the resident from the female resident's room, but there was no evidence of any other intervention to reduce or prevent these behaviors. On 09/07/10, the resident was seen by his physician. The physician's progress notes on that date contained nothing relative to the resident's behaviors, and there was no evidence the physician had been made aware of the resident's behaviors. In addition, the physician made no recommendations or addressed any of the behaviors the resident had been exhibiting. During an interview on 12/09/10 at 11:51 a.m., the administrator confirmed it was her preference to not permit the resident to return to the facility. She said, ""We told the resident it was not appropriate behavior."" On 12/09/10 at 12:59 p.m., the social service department at the hospital was contacted and confirmed the facility had prearranged placement at another facility prior to Resident #35 being transferred to the hospital on [DATE]. The social service staff member confirmed the facility had said they could not take him back. On 12/09/10, the responsible party for Resident #35 was contacted and said he was told the facility could not take Resident #35 back because of his behaviors. He said he would rather Resident #35 stay at this facility, since the new facility was located 120 miles away. The responsible party stated, ""The facility said they could not take him back."" At the time the resident was transferred to the hospital for an evaluation regarding his behaviors on 09/24/10, there was no evidence the facility had made any attempts to determine causal factors which may have contributed to the resident's behaviors, and no evidence of the provision of medically-related social services or services from an appropriate mental health professional to address these behaviors. In addition, the care plan did not address the variety of behaviors and/or have interventions which would lead to problem identification and/or correction. There was no evidence to reflect the facility attempted to meet the resident's needs prior to making the determination that they could no longer care for him. .",2014-04-01
11361,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,279,E,,,GCMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, staff interview, family interview, and resident interview, the facility failed to develop comprehensive care plans and/or interventions for four (4) of thirty-two (32) Stage II sample residents. There was no care plan for intentional weight loss for Resident #43; no care plan for foot care for Resident #5; no interventions for behaviors for Resident #35; and no restorative care plan for Resident #115. Resident identifiers: #43, #5, #35, and #115. Facility census: 83. Findings include: a) Resident #43 During an interview with the resident on 12/08/10 at 3:15 p.m., the resident revealed she was trying to lose weight, stating, ""I really want to get rid of my belly."" Review of the dietary progress notes, dated 08/26/10 and 09/29/10, revealed the registered dietician had noted the resident was trying to lose weight. Review of the dietary progress notes, dated 10/26/10, revealed the dietary supervisor (Employee #68) also noted: ""Resident wants to lose wt (weight)."" Review of the dietary progress notes, dated 11/30/10, revealed the dietary supervisor noted: ""Resident wants to continue to lose wt per her choice due to history of diabetes."" An interview on 12/08/10 at 2:15 p.m., with a registered nurse (RN - Employee #77), revealed the resident frequently requested junk food and had yet to mention to her (Employee #77) that she wanted to lose weight. Review of the resident's care plan found no mention of a plan to assist the resident in achieving intentional weight loss. b) Resident #5 On 12/06/10, a family interview was conducted with this resident's sister. During the interviewed, the sister expressed concern that the resident's feet were not routinely cleaned by facility staff. She stated the resident's feet were often dry and flaky, and that she (the sister) often soaked and cleaned them herself. Interview with the resident, at 1:00 p.m. on 12/07/10, revealed her feet were always cold, so she wore socks all the time. Further interview revealed the resident was rarely showered due to her severe pain, and she preferred bed baths. Upon inquiry, the resident stated she did not feel her feet received the care they required, and that her sister often had to soak them and clean them. She stated staff did not perform this care routinely. Review of the resident's care plan, on 12/07/10, revealed no specific care plan regarding the resident's foot care. On 12/08/10 at 9:00 a.m., this resident's feet were observed with an RN (Employee #20). The resident's feet were dry and flaky. According to Employee #20, the resident needed foot care. Employee #20 stated she would assure the resident received this care. c) Resident #35 Medical record review revealed this resident was admitted to the facility on [DATE] for a long-term stay. According to the facility's interdisciplinary discharge plan dated 2/09/10, the plan for discharge on admission was for ""definite long-term stay"". He was admitted with [DIAGNOSES REDACTED]. Review of the medical record also revealed the resident's vision was poor, and his hearing was so poor he used a communication board to communicate his needs. Medical record review revealed the resident resided at the facility from 02/08/10 until 07/03/10 with no inappropriate behaviors. According to the medical record, on 07/03/10, the resident smashed the light in his room with his trapeze bar. On 07/26/10, he was witnessed hitting the wall with the trapeze bar. On 07/29/10, he slammed the bedside chair and water pitcher into the wall and hit the nurse. On 08/01/10, he was pounding on the wall with the trapeze bar. On 08/08/10, he made vulgar comments to a nursing assistant. On 08/16/10, he was found outside in the courtyard smoking. The cigarette was taken from him and he was told the facility is a non-smoking facility. On 08/17/10, he hit the wall with the trapeze bar. The facility did not initiate a care plan to address behaviors until 08/26/10, when the resident exhibited inappropriate sexual behaviors toward staff, and the intervention was to ""redirect resident"". No other behaviors were identified and/or addressed on the care plan. The care plan provided no methods for implementing this redirection. d) Resident #115 During an observations of the dinner meal on 11/29/10 at 6:00 p.m., Resident #115 was observed to be eating in the area designated as the restorative dining area. She was falling asleep. After the others were served, the restorative nursing assistant fed the resident her meal. The medical record, when reviewed on 11/30/10, found Resident #115 had been evaluated by the speech-language pathologies (SLP) for dysphagia with recommendations made on 11/12/10. The SLP stated the goal for this resident was ""to decrease risk of aspiration and increase PO (by mouth) intake"". The recommendations included: placement of the resident in the restorative feeding program; she was not to have straws in her drinks, she was to be provided verbal cueing to swallow with her meals due to her issue of pocketing food in her mouth; and she was to have two (2) to three (3) bites of food alternated with one (1) drink. The resident's most recent interdisciplinary care plan, dated 11/22/10, was reviewed. This plan did not include a restorative nursing care plan, did not identify this resident was at risk for aspiration, and did not include interventions to prevent aspiration and address the resident's swallowing problems as recommended by the SLP. The restorative nursing assistant (Employee #94) was observed feeding this resident lunch at 12:15 p.m. on 12/02/10. The resident had a straw in her milk and was given four (4) to five (5) bites between drinks, instead of two (2) to three (3) bites as recommended by the SLP. The director of nursing (DON), when interviewed at 3:30 p.m. on 12/03/10, reviewed the resident's care plan and verified there was no restorative care plan. .",2014-04-01
11362,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,319,D,,,GCMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide appropriate treatment and services to assist one (1) of thirty-two (32) Stage II sample residents related to behavioral problems. Resident #35 was sent out to the hospital for a behavioral evaluation on 09/24/10. The resident had several behavioral incidents for which there was no evidence of assessment to determine the causative factors for the behaviors. Resident identifier: #35. Facility census: 83. Findings include: a) Resident #35 Medical record review revealed this resident was admitted to the facility on [DATE] for a long-term stay. According to the facility's interdisciplinary discharge plan dated 2/09/10, the plan for discharge on admission was for ""definite long-term stay"". He was admitted with [DIAGNOSES REDACTED]. Review of the medical record also revealed the resident's vision was poor, and his hearing was so poor he used a communication board to communicate his needs. Medical record review revealed the resident resided at the facility from 02/08/10 until 07/03/10 with no inappropriate behaviors. According to the medical record, on 07/03/10, the resident smashed the light in his room with his trapeze bar. On 07/26/10, he was witnessed hitting the wall with the trapeze bar. On 07/29/10, he slammed the bedside chair and water pitcher into the wall and hit the nurse. On 08/01/10, he was pounding on the wall with the trapeze bar. On 08/08/10, he made vulgar comments to a nursing assistant. On 08/16/10, he was found outside in the courtyard smoking. The cigarette was taken from him and he was told the facility is a non-smoking facility. On 08/17/10, he hit the wall with the trapeze bar. The medical record contained no evidence of efforts by the facility to identify of causative factors and/or interventions for any of the documented behavioral episodes. There was no evidence that staff considered the need for medically-related social services or services from an appropriate mental health professional to address this resident's behavioral issues. The facility did not initiate a care plan to address behaviors until 08/26/10, when the resident exhibited inappropriate sexual behaviors toward staff, and the intervention was to ""redirect resident"". No other behaviors were identified and/or addressed on the care plan. The care plan provided no methods for implementing this redirection. On 09/06/10, the resident was verbally sexually inappropriate with staff, and on 09/07/10, he bit a nursing assistant on the breast. There was no evidence of attempts at redirection. Staff just told this confused resident his behaviors were ""inappropriate"". Further review of the medical record revealed nursing documentation for 09/24/10 at 5:00 a.m., at which time the registered nurse (RN) supervisor (Employee #20) was notified Resident #35 was found on two (2) occasions the previous evening in a female resident's room exhibiting inappropriate sexual behaviors. Staff removed the resident from the female resident's room, but there was no evidence of any other intervention to reduce or prevent these behaviors. On 09/07/10, the resident was seen by his physician. The physician's progress notes on that date contained nothing relative to the resident's behaviors, and there was no evidence the physician had been made aware of the resident's behaviors. In addition, the physician made no recommendations or addressed any of the behaviors the resident had been exhibiting. At the time the resident was transferred to the hospital for an evaluation regarding his behaviors, there was no evidence the facility had made any attempts to determine causal factors which may have contributed to the resident's behaviors, and no evidence of the provision of medically-related social services or services from an appropriate mental health professional to address these behaviors. .",2014-04-01
11363,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,364,F,,,GCMN12,". Based on observation, test tray temperatures, and staff interview, the facility failed to assure foods were attractive, appetizing, and at the proper temperature when received by the residents. Pureed foods were thin and ran into each other on the plate for twenty (20) residents who were provided pureed diets. Additionally, the temperature of coleslaw was too warm for palatability, at the point of service, for all residents. These practices affected all facility residents who received nourishment from the dietary department. Facility census: 84. Findings include: a) On 02/24/11 during the noon meal, observations were made of residents eating in the activity room. The pureed foods (pinto beans, sauerkraut, and polish sausage) ran together touching each other on the plates. This created an unappetizing presentation for the twenty (20) residents who required pureed foods. There was no form to the foods at all. The foods on the plates were touching each other, edge to edge, with color being the only distinguishing factor from one food to the other. This was shown to the administrator (NHA - Employee #117) and the director of nursing (DON - Employee #118) at the time of the observation. The NHA confirmed the meals served to residents on pureed diets were not appetizing or attractive. -- b) At noon on 03/02/11, pureed meals were observed with the dietary manager (DM - Employee #63). The pureed broccoli mix and pureed ranch style beans were thin, without form, and ran into each other on the plates. At that time, the DM confirmed the foods should have form and not spread into each other. -- c) On 03/02/11 at 12:55 p.m., a test tray was requested to be placed on the cart immediately following the last resident to be served at the noon meal. There was a misunderstanding, and the cart on which the test tray was placed was not the last cart to be served. In addition, it contained only three (3) trays. The meals on this cart had no wait time for service; however, the foods were tested anyway, with the DM. The hot foods were at appropriate temperatures; however, the cold food (coleslaw) was 51.4 degrees Fahrenheit (F). According to State law, cold foods, at the time of receipt, can measure no more than 50 degrees F. Due to the confusion of getting test trays, another test tray was requested. This one was immediately following the last tray served in the dining room. The tray was tested at 1:15 p.m., with the DM. The hot foods were again at appropriate temperatures; however, the coleslaw was 54.7 degrees F. Upon inquiry, the DM stated the coleslaw was prepared that morning. When asked the size and depth of the pan used to chill the coleslaw, the DM showed the surveyor a 6-inch deep 1/2 steam table pan. This pan was not shallow enough to allow for rapid chilling of cold foods. .",2014-04-01
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
11368,VALLEY HAVEN GERIATRIC CENTER,515123,"RD 2, BOX 44",WELLSBURG,WV,26070,2009-03-18,431,E,,,IFJQ11,"Based on an observation and staff interview, the facility did not ensure that two (2) of two (2) treatment carts were entered only by authorized personnel. A nursing assistant was permitted to have a key to open both treatment carts, which contained supplies and topical medications prescribed to residents by the physician. Facility census: 53. Findings include: a) An observation, on 03/18/09 at 10:00 a.m., revealed a nursing assistant (NA) was assisting the treatment nurse with resident treatments on 200 hall of the facility. The NA was observed using a key to enter the treatment cart and remove treatment supplies. An interview the NA, on 03/18/09 at 10:30 a.m., revealed she assisted the treatment nurse and was permitted to have a key to open both treatment carts. She also stated she would retrieve the necessary supplies and treatments (which would include physician-ordered topical medications) for the nurse. .",2014-04-01
11369,VALLEY HAVEN GERIATRIC CENTER,515123,"RD 2, BOX 44",WELLSBURG,WV,26070,2009-03-18,225,D,,,IFJQ11,"Based on facility record review and staff interview, the facility failed to make reasonable efforts to uncover criminal histories of two (2) sampled employees, by failing to conduct criminal background checks in all States in which these employees had previously worked. Employee identifiers: #1 and #4. Facility census: 53. Findings include: a) Employee #1 A review of the personnel file of Employee #1, who was hired on 01/21/08, revealed she possessed a nursing license from the Commonwealth of Pennsylvania, and information on her her employment application indicated prior work history in that State. However, there was no evidence of efforts by the facility to inquire about possible criminal convictions in that State which would have made her unsuited to work in a nursing facility. This was verified by the administrator after he had reviewed the file himself. b) Employee #4 A review of the personnel file of Employee #4, who was hired on 12/23/08, revealed prior work history in the State of Ohio. However, there was no evidence of efforts by the facility to inquire about possible criminal convictions in that State which would have made her unsuited to work in a nursing facility. This was verified by the administrator after he had reviewed the file himself. .",2014-04-01
11370,VALLEY HAVEN GERIATRIC CENTER,515123,"RD 2, BOX 44",WELLSBURG,WV,26070,2009-03-18,314,G,,,IFJQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation,and staff interview, the facility failed to provide the necessary care and services to prevent new pressure sores from developing for one (1) of three (3) residents whose medical records were reviewed for pressure ulcers. Resident #16 had been assessed as being at low risk for development of pressure ulcers. Medical record review revealed the resident developed a pressure ulcer, which was treated, healed, and then re-opened, because the facility failed to provide a pressure relieving device for chairs in which the resident spent most of the day sitting. Resident identifier: #16. Facility census: 53. Findings include: a) Resident #16 Medical record review revealed Resident #16 developed a pressure ulcer on 01/08/09. The resident was treated, and staff recorded the wound was healed on 02/16/09, after which preventive treatment was used. Review of the resident's Braden Scale, used to predicting pressure sore risk, revealed the resident was rated as being at mild risk for the development of pressure sores. During a treatment on 03/17/09 at 10:00 a.m., observation revealed the resident had a red area on the lower coccyx at the cleft of the buttocks. When the treatment nurse cleansed the red area, observation revealed two (2) small areas open areas which measured 0.2 x 0.2. Interview with the treatment nurse (Employee #80) during this observation revealed the area had been healed and these two (2) areas had just re-opened. When the treatment nurse was questioned as to why the resident had developed a pressure ulcer and why the area had re-opened, the nurse indicated the resident spent a large part of her day sitting in a chair at the nurse's station, and she stated the resident probably needed a pressure relieving cushion. On 03/17/09, observations found the resident moved independently in bed and was ambulatory with a walker and staff assistance. Observations beginning at 11:00 a.m. found the resident sitting in a chair in front of the nurse's station; at 2:15 p.m., staff assisted the resident to bed to be seen by the physician. The chair in which the resident sat was wooden with a curved back and a small flat cushion built onto the chair seat. Review of physician's orders [REDACTED]. On 03/18/09 at 11:30 a.m., observation again found the resident sitting in the wooden chair in front of the nurse's station. During a subsequent interview at 12:05 p.m. on 03/18/09, the treatment nurse (Employee #80) was asked if the small flat cushion which was built onto the resident's chair was adequate as a pressure relieving device, and she stated it was not adequate. .",2014-04-01
11371,VALLEY HAVEN GERIATRIC CENTER,515123,"RD 2, BOX 44",WELLSBURG,WV,26070,2009-03-18,329,D,,,IFJQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interview, the facility failed to ensure the medication regimen of one (1) of ten (10) sampled residents was free of unnecessary drugs. Resident #21, who was receiving 2 mg a day of [MEDICATION NAME] (greater than the maximum daily dosage recommended for geriatric residents), was exhibiting no behaviors for which the medication was originally ordered, had the medication held on several occasions due to sleeping, and had no attempted gradual dose reduction for ten (10) months. Resident identifier: #21. Facility census: 53. Findings include: a) Resident #21 A review of the resident's medical record indicated this [AGE] year old female was admitted to the nursing facility on 05/07/08, with a physician's orders [REDACTED]."" The resident continued to the present to receive the original dose [MEDICATION NAME] 0.5 mg four (4) times a day, for a total of 2 mg a day. A review of the facility's behavior record indicated that, for the months of February 2009, January 2009, December 2008 , November 2008, and October 2008, the resident did not exhibit any behaviors. The behaviors identified on this record for monitoring included agitation over need to leave and exit-seeking behavior. A review of the physician's progress notes revealed that only one (1) entry addressing the [MEDICATION NAME], dated 11/25/08, in which the physician indicated, ""Continue [MEDICATION NAME] less overall anxiety and less of a fall risk at present."" Observations of the resident, on 03/11/09 at 3:30 p.m. and 03/12/09 at 11:00 a.m., revealed the resident sitting in a wheelchair with the staff moving the resident to other locations in the facility. An observation of the resident, on 03/16/09 at 10:30 a.m.. revealed the resident lying in bed sleeping. Later at 2:30 p.m., the resident was again observed lying in bed sleeping. A nursing note, dated 02/26/09 (no time was documented), indicated the resident was lethargic related to not sleeping most of the night. The resident's [MEDICATION NAME] was held for the 1:00 p.m. dose. On 02/27/09 at 9:00 a.m., a nursing note indicated the resident was sleeping and the breakfast tray was held. On 03/01/09 at 9:00 a.m., a nursing note again indicated the resident was sleeping and the breakfast tray was held. A review of the CMS Appendix N for unnecessary medication revealed the recommended daily dose for the geriatric resident for the short acting benzodiazepine drugs ([MEDICATION NAME]) was 0.75 mg. A gradual dose reduction should be attempted at least twice within one (1) year. Resident #21 was receiving 2 mg a day and with no attempted dose reduction for ten (10) months. .",2014-04-01
11372,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2010-12-11,371,F,,,RUPW11,". Based on observation and staff interview, the facility failed to assure that two (2) male dietary aides wore effective hair restraints to prevent potential contamination of food by facial hair. This unsanitary practice had the potential to affect all residents receiving an oral diet. Facility census: 80. Findings include: a) An inspection of the dietary department, during the noon meal on 12/11/10 at 12:20 p.m., noted one (1) male dietary aide (Employee #3) was assisting with the service of the noon meal. Observation found Employee #3 had approximately 1/2 inch hair growth on his lip and chin with no beard guard in use to prevent his facial hair from potentially contaminating the food being served. Further observation found another male dietary employee (Employee #4) making peanut butter and jelly sandwiches in an adjacent room. Observation found Employee #4 had facial hair on his lip, chin, and along his jaw with no beard guard in place. When asked why he was not wearing a hair restraint on his beard and mustache, he stated that he had only worked there about three (3) weeks and had never been told he needed to wear anything on his face.",2014-04-01
11373,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-01-13,441,E,,,JK1V11,". Based on observation, staff interview, and a review of the facility's handwashing policy and procedures, the facility failed to ensure four (4) of nine (9) nursing employees observed washed their hand in accordance with acceptable hand hygiene practices per the facility's handwashing policy. Employees #102, #27, #71, and #155 were observed to turn off the faucet with their hands before drying their hands and without obtaining a clean paper towel to turn off the water. This had the potential to affect any resident receiving care from these employees after their hands became recontaminated from contact with the water faucet. Resident identifiers; #39, #115, #36, and #22. Facility census: 132 Findings included: a) Employee #102 During observations made on 01/12/11 at 1:30 p.m., a registered nurse (RN - Employee #102) was observed while washing her hands and after providing perineal care to Resident #39. She turned off the water faucet after washing her hands without obtaining a paper towel to dry her hands and to turn off the water faucet. This occurred for two (2) of three (3) handwashing observations for this employee. -- b) Employee #27 During observations made on 01/12/11 at 1:45 p.m., a nursing assistant (Employee #27) was observed while washing her hands and after providing perineal care to Resident #115. She turned off the water faucet after washing her hands without obtaining a paper towel to dry her hands and to turn off the water faucet. This occurred for one (1) of two (2) handwashing observations for this employee. -- c) Employee #71 During observations made on 01/12/11 at 1:45 p.m., a licensed practical nurse (LPN - Employee #71) was observed while washing her hands and after providing perineal care to Resident #115. She turned off the water faucet after washing her hands without obtaining a paper towel to dry her hands and to turn off the water faucet. This occurred for one (1) observation for this employee. -- d) Employee #155 During observations of incontinence care on 01/12/11 between 3:10 p.m. and 3:40 p.m., a nursing assistant (Employee #155) was observed assisting with the care of Residents #36 and #22. She washed her hands, turned off the sink faucet with her hand, and then proceeded to dry her hands with a paper towel and put it in the trash. -- e) Review of the facility policy / procedure on handwashing (dated 01/20/10) revealed, in Section C, Item #3, that after washing hands, staff was to use a paper towel to turn off the faucet. -- f) During an interview on 01/13/11 at 10:30 a.m., the director of nursing (Employee #171) reported her expectation that all employees were to follow the facility's handwashing policy and procedure and use a paper towel to turn off the faucet.",2014-04-01
11374,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2011-01-05,257,E,,,TDRO11,". Based on observation, confidential family interview, confidential resident interviews, and staff interview, the facility failed to maintain an environment with temperatures that were comfortable for the residents. Residents expressed that it was often cold in the front hallway area of the facility that leads to the outside. This was an area frequented by residents and visitors, and persons had to pass through this area to access the activity room, the dining area, and the therapy room. The uncomfortably cold temperature of this area had the potential to affect more than an isolated number of residents. Facility census: 57. Findings include: a) During a tour of the facility on 01/03/11 beginning at 1:00 p.m., the temperatures in different areas of the facility were measures, and all areas were found to be above 72 degrees Fahrenheit (F) except the front lobby. The maintenance supervisor (Employee #3) was asked to place a thermometer in this area, so the temperature could be monitored in the hall. Using the facility's own thermometer, the temperature in that hallway at that time was 68 degrees F. Observation also found the heater on the hall in that area was not turned on at that time. - A confidential family interview, conducted on the afternoon of 01/03/11, revealed the facility's temperatures fluctuated a lot, and it was often very cold in this hallway. She stated her mother, who often sites in the hallway, gets very cold, and staff does put a blanket on her, but she would feel the end of her mother's nose and find it to be ""cold as ice"". - Confidential interviews with alert and oriented residents identified six (6) residents who felt the ambient temperature of this area was uncomfortably cold. One (1) resident stated, ""When it is real cold outside, you can not hardly stand to come through that area, but you have to go through it to get to the dining room. Then you are cold when you get in the dining room, because you came through that cold air."" Another resident commented that it was very cold in the area when it is real cold outside. One resident said it was cold there and she just tried to hurry through that area and hoped that nothing slowed her down when it is cold. Another resident reported her room was nice and warm, and sometimes she doesn't want to come up front, because she has to go through that cold area. ""Sometimes you have a hard time getting through if it is congested, and there are a lot of people in that area. She stated, ""Sometimes there's a lot of action going on in that area, and you can't get through very fast."" She did not like to linger in that area because of the cold temperature. - Observations of the front lobby area, from 01/03/11 to 01/05/11, found the door was opened very frequently for visitors, the ambulance, and for some deliveries. On the days of the observations and interviews, the exterior temperature was 41 degrees F, while the interior temperature of this area only got up to 68 degrees F. - During an observation on 01/04/11 at 10:00 a.m., Resident #14 was found sitting in front hallway. This resident was dependent on the staff for mobility, and staff had parked her in the front hallway in her wheelchair. At 10:01 a.m., the temperature of the resident's room, where she had been before being brought to the front hallway, was found to be 80 degrees F. Resident #14 was transported from a room measuring 80 degrees to the front hallway measuring 68 degree F. Resident #14 was observed sitting in this hallway until 11:15 a.m. She did have a blanket laying over her, but the air was still cool to breathe and cool on her face after having previously been in a really warm room. This resident was confused and did not communicate; she could not have told staff that she was cold or ask anyone to move her to another area. - During an interview with Employee #3 on 01/04/11, he verified this area was only warmed up to 68 degrees F with the extra wall heater running. He also verified that, when it was really cold outside, this area was difficult to keep warm, and this was where the residents liked to sit. He verified that, with only one (1) single door in this area leading to the outside, when it was outside outside of the facility, this hallway would get cold every time the door was opened. .",2014-04-01
11375,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2011-01-05,323,D,,,TDRO11,"**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 free of accident hazards, by applying elevated half side rails to the bed of one (1) of seven (7) residents without first determining these half rails were necessary and safe for use. The facility assessed Resident #43 for the need for side rails on his bed, and his most recent assessment revealed the use of side rails was not indicated. The resident was observed, on 01/05/11, to have half side rails up. This resident was confused, he required staff assistance with transfers and mobility, and he had a history of [REDACTED]. Resident identifier: #43. Facility census: 57. Findings include: a) Resident #43 Observation of Resident #43, on 01/05/11 at 10:00 a.m., found him in bed with a half side rail in the elevated position. The nursing assistant (NA - Employee #29) caring for Resident #43 was interviewed at 10:05 a.m. on 01/05/11, regarding the use of side rails on this resident's bed. This employee stated Resident #43 used side rails to turn and reposition himself in bed. When asked how she determines who was suppose to use bed rails, she stated that the rails were secured down and could not be raised on the beds of residents who were not to use the rails. Review of Resident #43's medical record found a side rail assessment completed on 11/01/11. This assessment indicated the resident did not meet the criteria for the use side rails. Further review of the medical record revealed his [DIAGNOSES REDACTED]. In an interview at 1:00 p.m. on 01/05/11, the director of nursing (DON - Employee #70) identified that Resident #43 should not have side rails used on his bed. She stated that he was confused and he was not supposed to have side rails. She verified the assessment completed on this resident showed that side rails were not indicated for this resident and, therefore, the side rails should not be used.",2014-04-01
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
11382,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2010-12-21,327,D,,,NKSJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of records from two (2) hospitals, and staff interview, the facility failed, for one (1) of five (5) sampled residents, to: (1) ensure a resident with a gastrostomy feeding tube received all 275 cc free water flushes in accordance with physician orders; (2) monitor the resident to ensure he was having adequate urinary output each shift and irrigate the resident's suprapubic catheter if his urinary output was less than 200 cc in an 8-hour shift in accordance with physician's orders [REDACTED]. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Resident Assessment Data Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. Although the assessor noted the resident had infection with a multi-drug resistant organism (MDRO), the assessor did NOT place checkmarks in the assessment to indicate the resident's active [DIAGNOSES REDACTED]. According to the State-specific section of this MDS, the resident had NOT acquired any MDRO infections since his last assessment, to include [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The assessor noted Resident #28 was alert, rarely / never able to make self understood or to understand others, with impaired short and long term memory and severely impaired cognitive skills for daily decision making. He required the extensive physical assistance of two (2) or more staff members for bed mobility, transferring, locomotion, dressing, toilet use, and personal hygiene, he was totally dependent on one (1) staff member for eating, he did NOT receive any nutrition through tube feeding (although elsewhere in his record was noted that he received feedings through a gastrostomy - ""PEG tube"" or ""[DEVICE]""), and he was frequently incontinent of bowel and had in place an indwelling urinary catheter (elsewhere in his record, it was noted to be a suprapubic catheter). Further review of assessment data revealed he was transferred (with return anticipated) to an acute care hospital on [DATE], and he returned to the facility on [DATE]. -- 2. Hospital #1 Records Review of the resident's hospital records revealed he arrived in the emergency room (ER) of Hospital #1 on 11/17/10. Notes written by the ER nursing staff stated, ""2240 (10:40 p.m.) Pt (patient) arrives /c (with) multi layers of Blankets (sic). Hot, moist skin Red (sic) in color. ... 11/17 (sic) 0040 (12:40 a.m. on 11/18/10) [MEDICATION NAME] (L) (left) D/C'd (discontinued) per physician, Blue (sic) tip sent to lab for culture. ..."" Review of the form titled ""ED Nursing Record - Adult Male - PRIMARY ASSESSMENT"", in the section titled ""EENT"" (ears, eyes, nose, throat) was written: ""Dried oral secretions (sic) oral membrane"". In the section titled ""Skin"" were circled the words ""diaphoresis"" and ""hot"". In the section titled ""Cardiovascular"" was written (next to the printed word ""[MEDICAL CONDITION]"") ""mild Bilat(eral) leg & arm"". Above the nurse's signature was written: ""hands / fingers swelled (sic) ..."" Documentation on the form titled ""ED Nursing Record - Adult Male - General Documentation"", under the heading ""I & O"" (fluid intake and output), noted the resident received 1000 cc of fluid (elsewhere identified as normal sterile saline - NSS) and voided 50 cc of urine while in the ER of Hospital #1. Documentation by the ER physician on a form titled ""Physical Exam"" identified the resident was lethargic and ""Patient much more alert /p (after) NS (normal saline) Bolus."" The resident was transferred from Hospital #1 to Hospital #2 related to the lack of a bed at Hospital #1, and the resident a direct admit into Hospital #2's intensive care unit ""because [MEDICAL CONDITION] secondary to urinary tract infection"". The resident arrived at Hospital #2 on the early morning of 11/18/10. -- 3. Hospital #2 Records The resident's Hospital #2 ""Discharge Summary"" revealed the following discharge Diagnoses: [REDACTED]. [MEDICAL CONDITION]. 2. Urinary tract infection. 3. [MEDICAL CONDITION] surrounding his suprapubic catheter and gastric tube site. 4. Catheter line associated bacteremia with Staphylococcus epidermis, all subsequent cultures negative."" Under the heading ""Hospital Course"" was noted, ""The patient was sent to (name of Hospital #1) from his nursing home for high fevers. He was found to have a highly positive urinary tract infection as well as pus surrounding his suprapubic catheter and [DEVICE] as well as some small scattered pressure sores. The patient is a known chronic quadriplegic from end-stage MS and has a history of recurrent urosepsis and ESBL positive organisms. The patient's ultimate infectious sources included a single blood culture positive for staph epidermidis ... He also had both areas of [MEDICAL CONDITION] positive for cultures with [MEDICAL CONDITION]-resistant Staphylococcus aureus as well as pseudomonas and ESBL positive Escherichia coli. Urine culture was positive for [MEDICATION NAME] which was [MEDICATION NAME] sensitive but [MEDICATION NAME] resistant, also positive for the ESBL. Escherichia coli as well. ... The patient resolved with routine treatment of [REDACTED]. -- 4. Record review, including a comparison was made of documentation found in the nursing notes, in the weights and vitals summary report (VSR), and on the November 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - From 09/25/10 until 11/04/10, the resident had no temperatures recorded in the VSR that exceeded a pre-established threshold that triggered further assessment. - Beginning on the early morning of 11/04/10, the resident had a fever of 100.6 degrees F (axillary) for which he was medicated with Tylenol 650 mg. He continued to have an elevated temperature on 11/05/10, at which time the nurse contacted the physician, who ordered the antibiotic [MEDICATION NAME] 1 gram IM everyday for three (3) days. On the telephone order, the indication for use of the [MEDICATION NAME] was ""UTI"". - According to the nursing notes, the last dose of this 3-day course of [MEDICATION NAME] was administered on 11/07/10. According to the November 2010 MAR, a nurse administered Tylenol 650 mg for an elevated temperature at 6:00 p.m. on 11/09/10, although there were no corresponding entries in either then nursing notes or the VSR to state what the temperature was. Per documentation on the MAR, additional doses of Tylenol 650 mg were administered for elevated temperatures on 11/11/10 (possibly twice, although one (1) entry was illegible), 11/13/10 (twice), 11/14/10, 11/15/10, and 11/16/10 (twice). - Staff did not notify the physician that Resident #28 continued to have intermittent fevers (beginning on 11/09/10) after completion of the first 3-day course of [MEDICATION NAME] on 11/07/10. Once notified of the resident's elevated temperature on 11/16/10, the physician ordered a second 3-day course of [MEDICATION NAME] 1 gram IM everyday for three (3) days for ""UTI"". The physician examined the resident on 11/16/10, recorded a [DIAGNOSES REDACTED]. -- 5. Regarding Maintaining Fluid Balance and Monitoring of Urinary Output Review of the physician's orders [REDACTED]. - ""[MEDICATION NAME] 1.5 at 85 cc (sic) hour for 20 hour cycle with 4 hours down time (sic) off at 6am (sic) on at 10 am (sic) continue with h2o (sic) flushes of 275cc (sic) every 4 hours for additional 1650ml (sic) a day. Hold if residual (sic) 100ml or over."" - ""Hand irrigate foley (sic) with 60 cc sterile H2O every 8 hours or as needed for output less than 200cc (sic)."" - ""Suprapubic cath eter (sic) check every shift for placement and function. May change cath when dysfunctional."" -- Review of his care plan revealed the following problem statement: ""I have an enteral feeding tube to meet nutritional needs due to impaired swallowing secondary to [MEDICAL CONDITION] MS."" (This problem statement had a ""Date Initiated"" of 04/30/10, was ""Created on"" 04/30/10, and was revised on 07/21/10.) Interventions associated with this problem statement included: ""Free H2O, 250ml q 4 hrs, as ordered."" (This intervention had a ""Date Initiated"" of 04/30/10 and was ""Created on"" 04/30/10.) Review of this 13-page care plan found no other problem statements, goals, or interventions addressing the resident's hydration status / fluid balance, although the resident was totally dependent on others to meet his nutrition and hydration needs. There was no acute care plan to address the resident ' s needs for additional free water flushes related to his intermittent fevers. There was also no care plan developed to address the need to hand irrigate the catheter with 60 cc of sterile water if the resident's urinary output was less than 200 cc in an 8-hour shift, although there was a physician's orders [REDACTED]. -- Review of the Enteral Protocol form for November 2010 revealed an order for [REDACTED]. Total Vol: ___ (left blank) ML/24 hours."" Beside this order was a series of blocks where the nurse was to initial having provided 275 cc of water at the following intervals daily: 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., 10:00 p.m., and 2:00 a.m. Initials were absent for a total of twenty-one (21) out of one hundred (100) possible flushes between 6:00 a.m. on 11/01/10 and 6:00 p.m. on 11/17/10. There was no evidence to reflect the additional free water flushes of 275 cc were provided as ordered for the following dates and times: - On 11/01/10 at 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10:00 p.m. - On 11/02/10 at 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., 10:00 p.m., and 2:00 a.m. - On 11/03/10 at 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10:00 p.m. - On 11/04/10 at 6:00 a.m., 10:00 a.m., and 2:00 a.m. - On 11/05/10 at 6:00 p.m. and 10:00 p.m. - On 11/15/10 at 6:00 p.m. and 10:00 p.m. -- Review of the treatment administration record (TAR) for November 2010 revealed an order for [REDACTED]. output was less than 200 cc. None of these blocks was initialed, even though one (1) nursing note, dated 11/17/10 at 6:01 p.m., specifically stated, "" ...Urinary output >200cc at this time."" -- Review of the resident's ""Bedside Intake and Output Records"" for the period of 11/01/10 through 11/17/10 revealed the following information regarding the resident's urinary output per 8-hour shift for the 11:00 p.m. to 7:00 a.m. (11-7), 7:00 a.m. to 3:00 p.m. (7-3), and 3:00 p.m. to 11:00 p.m. (3-11) shifts: Date - 11-7 - 7-3 - 3-11 = 24-hour total 11/01/10 - 400 cc - (blank) - (blank) = 400 cc 11/02/10 - 350 cc - (blank) - (blank) = 350 cc 11/03/10 - (blank) - (blank) - (blank) = 0 cc 11/04/10 - 450 cc - (blank) - (blank) = 450 cc 11/05/10 - 600 cc - (blank) - (blank) = 600 cc 11/06/10 - 800 cc - (blank) - (blank) = 800 cc 11/07/10 - 700 cc - (blank) - (blank) = 700 cc 11/08/10 - 450 cc - (blank) - (blank) = 450 cc 11/09/10 - no record available 11/10/10 - no record available 11/11/10 - 225 cc - (blank) - (blank) = 225 cc 11/12/10 - 450 cc - (blank) - 325 cc = 775 cc 11/13/10 - no record available 11/14/10 - no record available 11/15/10 - 250 cc - (blank) - (blank) = 250 cc 11/16/10 - no record available 11/17/10 - 350 cc - (blank) - (blank) = 350 cc No additional documentation was found elsewhere in the resident's record to reflect staff was monitoring and recording his urinary output during each 8-hour shift, to identify the need for the 60 cc flushes or to assess the resident's hydration status. -- An interview with the ADON, on 11/21/10 at 9:30 a.m., revealed the resident required more free water added to the gastric tube, because of the intermittent fevers during the month of November. .",2014-04-01
11383,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2010-12-21,224,G,,,NKSJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of records from two (2) hospitals, review of facility policies and procedures, review of information published on the Internet related to the topics of ""fever"" and ""axillary temperature"", and staff interview, the facility failed to provide goods and services necessary to avoid physical harm to one (1) of five (5) residents (#28). The facility failed to: (1) obtain and consistently record in the same place in the electronic medical record Resident #28's vital signs (e.g., temperature) every shift in accordance with his care plan related to antibiotic administration via his central line for the treatment of [REDACTED]. Tylenol in accordance with physician orders [REDACTED]. line insertion site and ostomy sites for signs of irritation or infection; (6) change the resident's central line dressing weekly in accordance with facility protocol; (7) ensure the resident received all 275 cc free water flushes in accordance with physician orders; (8) monitor the resident to ensure he was having adequate urinary output each shift and irrigate the resident's suprapubic catheter if his urinary output was less than 200 cc in an 8-hour shift in accordance with physician's orders [REDACTED]. the resident exhibited intermittent elevated temperatures beginning two (2) days after having completed a 3-day course of antibiotic for a UTI. This failure to provide necessary goods and services resulted in physical harm to Resident #28, who was transferred to a hospital on [DATE] and was subsequently diagnosed with [REDACTED]. Facility census: 68. Findings include: a) Resident #28 1. Resident Assessment Data Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. Although the assessor noted the resident had infection with a multi-drug resistant organism (MDRO), the assessor did NOT place checkmarks in the assessment to indicate the resident's active [DIAGNOSES REDACTED]. According to the State-specific section of this MDS, the resident had NOT acquired any MDRO infections since his last assessment, to include [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The assessor noted Resident #28 was alert, rarely / never able to make self understood or to understand others, with impaired short and long term memory and severely impaired cognitive skills for daily decision making. He required the extensive physical assistance of two (2) or more staff members for bed mobility, transferring, locomotion, dressing, toilet use, and personal hygiene, he was totally dependent on one (1) staff member for eating, he did NOT receive any nutrition through tube feeding (although elsewhere in his record was noted that he received feedings through a gastrostomy - ""PEG tube"" or ""[DEVICE]""), and he was frequently incontinent of bowel and had in place an indwelling urinary catheter (elsewhere in his record, it was noted to be a suprapubic catheter). Further review of assessment data revealed he was transferred (with return anticipated) to an acute care hospital on [DATE], and he returned to the facility on [DATE]. -- 2. Hospital #1 Records Review of the resident's hospital records revealed he arrived in the emergency room (ER) of Hospital #1 on 11/17/10. Notes written by the ER nursing staff stated, ""2240 (10:40 p.m.) Pt (patient) arrives /c (with) multi layers of Blankets (sic). Hot, moist skin Red (sic) in color. ... 11/17 (sic) 0040 (12:40 a.m. on 11/18/10) [MEDICATION NAME] (L) (left) D/C'd (discontinued) per physician, Blue (sic) tip sent to lab for culture. ..."" Review of the form titled ""ED Nursing Record - Adult Male - PRIMARY ASSESSMENT"", in the section titled ""EENT"" (ears, eyes, nose, throat) was written: ""Dried oral secretions (sic) oral membrane"". In the section titled ""Skin"" were circled the words ""diaphoresis"" and ""hot"". In the section titled ""Cardiovascular"" was written (next to the printed word ""[MEDICAL CONDITION]"") ""mild Bilat(eral) leg & arm"". Above the nurse's signature was written: ""hands / fingers swelled (sic) ..."" Documentation on the form titled ""ED Nursing Record - Adult Male - General Documentation"", under the heading ""I & O"" (fluid intake and output), noted the resident received 1000 cc of fluid (elsewhere identified as normal sterile saline - NSS) and voided 50 cc of urine while in the ER of Hospital #1. Documentation by the ER physician on a form titled ""Physical Exam"" identified the resident was lethargic, his abdomen was distended and tympanic, ""decubiti"" (pressure sores) were present ""multi site"", and the resident had a [MEDICATION NAME] central line with a dressing labeled ""11/9/10"". ""Patient much more alert /p (after) NS (normal saline) Bolus."" In addition to a culture of the [MEDICATION NAME] central line catheter tip, the physician ordered urine and blood cultures. The physician reviewed the results of a urine culture and sensitivity from a previous admission, found the organism previously cultured was E. coli that was positive for extended spectrum beta lactamase (which was resistant to [MEDICATION NAME] and sensitive to Imipenem), and ordered intravenous [MEDICATION NAME] and Imipenem ([MEDICATION NAME]). The [MEDICATION NAME] was started, and the [MEDICATION NAME] was sent with him (""Start [MEDICATION NAME] when [MEDICATION NAME] complete"") when he was transferred to Hospital #2 at 0350 (3:50 a.m.) on 11/18/10. -- 3. Hospital #2 Records The resident was transferred from Hospital #1 to Hospital #2 related to the lack of a bed at Hospital #1, and the resident a direct admit into Hospital #2's intensive care unit ""because [MEDICAL CONDITION] secondary to urinary tract infection"". The resident arrived at Hospital #2 on the early morning of 11/18/10. The resident's Hospital #2 ""History and Physical"" revealed under the heading ""History of Present Illness"": ""This is a [AGE] year-old Caucasian male with a history of end-stage [MEDICAL CONDITION], depression, chronic [MEDICAL CONDITION], gastroparesis, [MEDICAL CONDITION] bladder, [MEDICAL CONDITION] reflux disease, [MEDICAL CONDITION], and recurrent urinary tract infection who was transferred (sic) (Hospital #1) to (Hospital #2) for direct admission to (sic) intensive care unit because [MEDICAL CONDITION] secondary to urinary tract infection. ... It seems the patient used to have a recurrent urinary tract infection in the past, but the last time he was found to have a urinary tract infection and got admitted to the hospital was in early 2010. Since the placement of (sic) cystostomy tube (a suprapubic catheter) in early 2010, the patient did not get admitted to the hospital because of urinary tract infection (sic). ..."" ""In the emergency room , the patient was evaluated by the ER physician who found the patient to [MEDICAL CONDITION] with temperature 101.8 degrees, heart rate in excess of 110 per minute and also respiratory rate in excess of 24 per minutes. His white blood cell count also was high at 14,600. Because he needed to be admitted and there was no hospital bed in the (name of Hospital #1), the patient has been transferred to (name of Hospital #2). I admitted the patient to the intensive care unit for close monitoring, because of his complicated previous history and also serious hospital admission."" Under the heading ""Impressions"" were noted: ""1. High fever, secondary [MEDICAL CONDITION]. 2. Urinary tract infection. ..."" Under the heading ""Plans"" were noted: ""1. Admit to ICU. 2. Blood and urine cultures which were done in the (Hospital #1) emergency room . Will send wound culture from cystostomy (suprapubic) tube area. 3. Empiric IV antibiotics with Imipenem, [MEDICATION NAME] (sic) and [MEDICATION NAME] will be continued, which were started in the emergency room in (name of Hospital #1). 4. IV hydration will be given cautiously. 5. Will continue home medications."" - The resident's Hospital #2 ""Discharge Summary"" revealed the following discharge Diagnoses: [REDACTED]. [MEDICAL CONDITION]. 2. Urinary tract infection. 3. [MEDICAL CONDITION] surrounding his suprapubic catheter and gastric tube site. 4. Catheter line associated bacteremia with Staphylococcus epidermis, all subsequent cultures negative."" Under the heading ""Hospital Course"" was noted, ""The patient was sent to (name of Hospital #1) from his nursing home for high fevers. He was found to have a highly positive urinary tract infection as well as pus surrounding his suprapubic catheter and [DEVICE] as well as some small scattered pressure sores. The patient is a known chronic quadriplegic from end-stage MS and has a history of recurrent urosepsis and ESBL positive organisms. The patient's ultimate infectious sources included a single blood culture positive for staph epidermidis, also listed from his catheter tip although I am not sure which catheter this was as it was not documented. Presumably it was some type of a central line. He also had both areas of [MEDICAL CONDITION] positive for cultures with [MEDICAL CONDITION]-resistant Staphylococcus aureus as well as pseudomonas and ESBL positive Escherichia coli. Urine culture was positive for [MEDICATION NAME] which was [MEDICATION NAME] sensitive but [MEDICATION NAME] resistant, also positive for the ESBL. Escherichia coli as well. ... The patient resolved with routine treatment of [REDACTED]. -- 4. Elevated Temperatures (a) Vitals Summary Report (VSR) A review of the resident's electronic medical record at the nursing facility revealed a weights and vitals summary report (VSR) for the period of 10/16/10 to 11/17/10 revealed the following consecutive entries: - 10/16/10 at 3:55 a.m. - 97.4 (axilla) - 11/05/10 at 10:51 p.m. - 99.2 (axilla) - High of 99.0 exceeded - 11/05/10 at 11:30 p.m. - 101.10 (axilla) - High of 99.0 exceeded - 11/06/10 at 12:51 a.m. - 98.1 (axilla) - 11/08/10 at 3:29 a.m. - 98.7 (axilla) - 11/09/10 at 3:37 a.m. - 97.2 (tympanic) - 11/09/10 at 9:52 p.m. - 97.2 (axilla) - 11/10/10 at 2:28 a.m. - 98.3 (axilla) - 11/10/10 at 11:45 a.m. - 98.2 (axilla) - 11/11/10 at 5:55 a.m. - 100.1 (axilla) - High of 99.0 exceeded - 11/11/10 at 5:56 a.m. - 97.8 (axilla) - 11/11/10 at 10:01 p.m. - 98.2 (axilla) - 11/12/10 at 4:41 a.m. - 98.7 (axilla) - 11/13/10 at 3:52 a.m. - 99.7 (axilla) - High of 99.0 exceeded - 11/13/10 at 2:07 p.m. - 97.4 (axilla) - 11/13/10 at 9:37 p.m. - 96.7 (axilla) - 11/14/10 at 4:59 a.m. - 97.8 (axilla) - 11/14/10 at 9:48 p.m. - 97.9 (axilla) - 11/15/10 at 2:50 a.m. - 97.5 (axilla) - 11/16/10 at 4:02 a.m. - 98.4 (axilla) - 11/17/10 at 5:08 a.m. - 99.5 (axilla) - High of 99.0 exceeded - 11/17/10 at 9:52 p.m. - 101.7 (axilla) - High of 99.0 exceeded - 11/17/10 at 10:54 p.m. - 102.4 (axilla) - High of 99.0 exceeded According to the VSR, between 09/11/10 and 11/05/10, Resident #28 had only one (1) temperature reading that was flagged for review as ""High of 99.0 exceeded"". This occurred at 2:37 p.m. on 09/23/10, at which time his axillary temperature measured 99.5 degrees F. -- (b) Nursing Notes Further review of the resident's electronic medical record at the nursing facility revealed the following consecutive nursing notes: - 10/13/10 at 5:45 p.m. - ""Temp: 98.7. zero (sic) signs or symptoms of distress (sic) will cont(inue) to monitor."" - 10/14/10 at 1:47 p.m. - ""Peg (sic) tube pulled out during care, scant amount of bleeding notes at site. Cleansed area with [MEDICATION NAME] (sic), replaced with 20Fr 15cc magna port (sic) Proper placement noted, flushes without difficulties. [MEDICATION NAME] 1.5cal (sic) running at 85cc/hr. no (sic) problems noted."" - 10/17/10 at 11:30 a.m. - ""REsident (sic) g tube (sic) flushed with ease and proper placement. 60cc (sic) of residual noted."" - 11/04/10 at 5:14 a.m. - ""Increased temp. of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) given vie (sic) peg tube. Will continue to monitor."" - 11/05/10 at 1:59 p.m. - ""Resident extremely sweaty (sic) temp taken 100.4ax (axillary). Contacted Dr. (name). Verbal order for [MEDICATION NAME] 1gram IM (intramuscular injection) qd (everyday) x 3 days for UTI. Will continue to monitor."" - 11/05/10 at 10:53 p.m. - ""Resident showing s/s (sign and symptoms of) illness as temp cont(inues) to rise. Tylenol via GT ([DEVICE]) given with decrease of temp at this time. ... Will continue to monitor."" ?- 11/06/10 at 9:54 p.m. - ""Temp 98.9 Axillary (sic) Resident continues on an ABT (antibiotic therapy) for UTI, no adverse reactions noted."" - 11/07/10 at 2:12 a.m. - ""Temp 97.2 axillary. Continues ABT related to UTI. ... No signs and symptoms of distress. Will monitor."" - 11/07/10 at 9:21 p.m. - ""Temp 98.1 (sic) Completed ABT today for UTI. 0 (no) adverse reactions noted."" - 11/09/10 at 3:36 a.m. - ""S/P (status [REDACTED]."" - 11/11/10 at 6:00 a.m. - ""temp (sic) 100.1 ax. tylenol (sic) 350mg (sic) per g.t. (sic) @ 0245."" - 11/11/10 at 4:36 p.m. - ""97.9 (sic) continues with tube feed of [MEDICATION NAME] ,flushes (sic) with ease. ... exhibits no signs of distress."" - 11/14/10 at 12:01 p.m. - ""VS (vital signs): 97 20 100/70 97.8. alert. Total care. Suprapubic cath patent. [DEVICE] flushed with each ... Zero signs or symptoms of distress noted. Will continue to monitor."" - 11/15/10 at 2:42 p.m. - ""Residents (sic) mothers (sic) was in today to visit ..."" - 11/16/10 at 6:57 a.m. - ""resident (sic) alert. total (sic) care.area (sic) around suprapubic cath.cleaned, (sic) temp 102.2 ax at 0500.tyleol (sic) 650mg per [DEVICE] given. resting (sic) at this time."" - 11/16/10 at 2:11 p.m. - ""Resident heard moaning from hallway (sic) Temp 100.6ax (sic). Gave tylenol (sic) 650mg via gt (sic). Called Dr. (name) (sic) verbal order given from [MEDICATION NAME] 1gram (sic) IM QD x3days (sic). Meds ordered from pharmacy. Resident resting quietly now."" - 11/17/10 at 3:34 p.m. - ""Temp 98.1ax (sic). New order [MEDICATION NAME] IV (intravenously) x3days (sic), ordered stat from pharmacy along with flushes and IV pump. [MEDICATION NAME] 1gram IV (intravenous) given via PICC at 1:30pm (sic) without difficulty. No adverse reactions noted. No s/s (signs / symptoms) IV complications noted."" - 11/17/10 at 6:01 p.m. - ""Resident moaning loudly, when asked if uncomfortable he said 'yeah'. V/S (vital signs) stable, tylenol (sic) given for apparent discomfort. GT turned off for time r/t (related to) abd (abdominal) discomfort. ... Will cont to monitor. Urinary output >200cc at this time. ABT [MEDICATION NAME] IM (sic) continues for UTI. No adverse effect noted. Fluid tolerated via GT."" - 11/17/10 at 8:28 p.m. - ""Monitoring resident frequently, no futhur (sic) moaning noted. Resting quietly. V/S remain stable, afebrile. T&P (turn and position) frequently. HOB (head of bed) ele (elevated) for comfort. Will continue to monitor."" - 11/17/10 at 9:48 p.m. - ""(Resident #28) transferred to hospital-unplanned (sic) for evaluation and treatment via ambulance to (name of Hospital #1). Physician notified of transfer. Physician called 2145 (9:45 p.m.) with info of condition change, order to send to (Hospital #1) for eval and tx (treat). Responsible party notified of transfer ..."" -- (c) Medication Administration Record (MAR) Review of the resident's November 2010 MAR revealed staff initialed having administered ""Tylenol 650 mg via GT ([DEVICE]) for temp > 101 Q 4 hours PRN (as needed)"" to Resident #28 on the following dates: - 11/05/10 at 11:45 p.m. - 11/09/10 at 6:00 p.m. - 11/11/10 at 2:45 a.m. - 11/11/10 (this second entry on 11/11/10 is illegible) - 11/13/10 at 2:30 a.m. - 11/13/10 at 5:00 p.m. - 11/14/10 at 5:00 p.m. - 11/15/10 at 8:00 p.m. - 11/16/10 at 5:00 a.m. - 11/16/10 at 11:00 a.m. - 11/17/10 at 5:45 p.m. -- (d) Comparison of VSR, Nursing Notes, and MAR Record review, including a comparison was made of documentation found in the nursing notes, in the VSR, and on the November 2010 MAR related to the administration of Tylenol for elevated temperatures, revealed the following: (1) From 09/25/10 until 11/04/10, the resident had no temperatures recorded in the VSR that exceeded a pre-established threshold that triggered further assessment. Beginning on the early morning of 11/04/10, the resident had a fever of 100.6 degrees F (axillary) for which he was medicated with Tylenol 650 mg. He continued to have an elevated temperature on 11/05/10, at which time the nurse contacted the physician, who ordered the antibiotic [MEDICATION NAME] 1 gram IM everyday for three (3) days. On the telephone order, the indication for use of the [MEDICATION NAME] was ""UTI"". According to the nursing notes, the last dose of this 3-day course of [MEDICATION NAME] was administered on 11/07/10. According to the November 2010 MAR, a nurse administered Tylenol 650 mg for an elevated temperature at 6:00 p.m. on 11/09/10, although there were no corresponding entries in either then nursing notes or the VSR to state what the temperature was. Per documentation on the MAR, additional doses of Tylenol 650 mg were administered for elevated temperatures on 11/11/10 (possibly twice, although one (1) entry was illegible), 11/13/10 (twice), 11/14/10, 11/15/10, and 11/16/10 (twice). All entries in the nursing notes between 11/04/10 and 11/16/10 were made by licensed practical nurses (LPNs). There was no evidence of any nursing assessment having been completed by an RN and recorded in the resident's nursing notes. Staff did not notify the physician that Resident #28 continued to have intermittent fevers (beginning on 11/09/10) after completion of the first 3-day course of [MEDICATION NAME] on 11/07/10. Once notified of the resident's elevated temperature on 11/16/10, the physician ordered a second 3-day course of [MEDICATION NAME] 1 gram IM everyday for three (3) days for ""UTI"". The physician examined the resident on 11/16/10, recorded a [DIAGNOSES REDACTED]. No labs were ordered during this period of intermittent fevers beginning on 11/04/10, in an effort to identify the infectious organism(s) and/or what antibiotic(s) would be effective in treatment. (According to labs collected at Hospitals #1 and #2, the resident had multiple infectious organisms at multiple sites (central line catheter tip, urine, blood, and at the insertion sites of his suprapubic catheter and gastrostomy tube), all of which were resistant to [MEDICATION NAME], meaning the [MEDICATION NAME] that was administered prior to the resident's transfer to Hospital #1 was ineffective in treating these infections.) The only entry made by an RN prior to his transfer to the hospital was recorded at 9:48 p.m. on 11/17/10. It contained no assessment information but stated the resident was transferred to the hospital ""unplanned"" for evaluation and treatment, after the physician was notified of a ""condition change"" at 2145 (9:45 p.m.), and an attempt was made to notify the resident's responsible party. -- (2) Not all temperatures were recorded in a single location in the resident's medical record where the user could access and review all temperature readings for analysis, tracking, and trending. On thirteen (13) occasions between 11/04/10 and 11/17/10, temperatures were recorded in the nursing notes (NN) and/or nurses initialed the MAR to indicate Tylenol was given for an elevated temperature, but no corresponding entry of a temperature reading was found on the VSR: - NN on 11/04/10 at 5:14 a.m. - ""Increased temp. of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) ..."" - MAR on 11/09/10 at 6:00 p.m. - Tylenol was given for elevated temperature - NN on 11/05/10 at 1:59 p.m. - ""Resident extremely sweaty (sic) temp taken 100.4ax (axillary). ..."" - MAR on 11/11/10 at 2:45 a.m. - Tylenol was given for elevated temperature. (A corresponding entry was also found in a NN at 6:00 a.m. on 11/11/10 as follows: ""temp (sic) 100.1 ax. tylenol (sic) 350mg (sic) per g.t. (sic) @ 0245."") - MAR on 11/13/10 at 2:30 a.m. - Tylenol was given for elevated temperature - MAR on 11/13/10 at 5:00 p.m. - Tylenol was given for elevated temperature - MAR on 11/14/10 at 5:00 p.m. - Tylenol was given for elevated temperature - MAR on 11/15/10 at 8:00 p.m. - Tylenol was given for elevated temperature - NN on 11/16/10 at 6:57 a.m. - ""... temp 102.2 ax at 0500.tyleol (sic) 650mg per [DEVICE] given. ..."" (A corresponding entry was also found on the MAR for 11/16/10 at 5:00 a.m.) - NN on 11/16/10 at 2:11 p.m. - ""... Temp 100.6ax (sic). Gave tylenol (sic) 650mg via gt (sic). ..."" - MAR on 11/16/10 at 11:00 a.m. - Tylenol was given for elevated temperature - NN on 11/17/10 at 3:34 p.m. - ""Temp 98.1ax (sic). ..."" - MAR on 11/17/10 at 5:45 p.m. - Tylenol was given for elevated temperature -- (3) Two (2) instances of elevated temperatures (greater than 100.0 degrees F axillary, which would be equivalent to 101 degrees F orally), which were recorded either in the VSR or NN, were not treated with Tylenol in accordance with standing orders: - NN on 11/05/10 at 1:59 p.m. - ""Resident extremely sweaty (sic) temp taken 100.4ax (axillary). ..."" - VSR on 11/17/10 at 9:52 p.m. - 101.7 (axilla) -- (4) Not all instances when Tylenol was administered were recorded on the MAR. On one (1) occasion between 11/04/10 and 11/17/10, a nurse recorded (in the nursing notes) having administered Tylenol to Resident #28, for which there was no corresponding entry in the MAR: - NN on 11/04/10 at 5:14 a.m. - ""Increased temp. (temperature) of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) ..."" -- (5) One (1) entry on the MAR (on 11/11/10) was illegible; therefore, it could not be ascertained whether a second dose of Tylenol was given or, if a second dose was given, at what time it was administered. -- (6) No documentation was found on the reverse side of the MAR, when Tylenol was given for an elevated temperature, of an assessment of the effectiveness of the PRN Tylenol in reducing the resident's temperature after administration. -- (e) References Obtained Via Internet (1) According to Medline Plus (a service of the U.S. National Library of Medicine / National Institutes of Health ), in an article titled ""Fever"": ""Fever is the temporary increase in the body's temperature in response to some disease or illness. ""... An adult probably has a fever when the temperature is above 99 - 99.5 ?F (37.2 - 37.5 ?C), depending on the time of day. ""... Call your doctor right away if you are an adult and you: - Have a fever over 105 ?F (40.5 ?C), unless it comes down readily with treatment and you are comfortable - Have a fever that stays at or keeps rising above 103 ?F - Have a fever for longer than 48 - 72 hours - Have had fevers come and go for up to a week or more, even if they are not very high - Have a serious medical illness, such as a heart problem, [MEDICAL CONDITION] cell [MEDICAL CONDITION], diabetes, [DIAGNOSES REDACTED], [MEDICAL CONDITION], or other chronic lung problems - Have a new rash or bruises appear - Have pain with urination - Have trouble with your immune system (chronic steroid therapy, after a bone marrow or organ transplant, had spleen removed, HIV-positive, were being treated for [REDACTED]. - Have recently traveled to a third world country"" (URL: http://www.nlm.nih.gov/medlineplus/ency/article/ 0.htm) -- (2) According to the Mayo Clinic, in an article titled ""Fever: First aid"": ""Fever is a sign of a variety of medical conditions, including infection. ""... Under the arm (axillary) ""Although it's not the most accurate way to take a temperature, you can also use an oral thermometer for an armpit reading: - Place the thermometer under your arm with your arm down. - Hold your arms across your chest. - Wait five minutes or as recommended by your thermometer's manufacturer. - Remove the thermometer and read the temperature. ""... An axillary reading is generally 1 degree Fahrenheit (about 0.5 degree Celsius) lower than an oral reading. ..."" (URL: ) -- (3) According to Drugs.com, in an article titled ""How To Take An Axillary Temperature"": ""What is it? ""An axillary (AK-sih-lar-e) temperature (TEM-per-ah-chur) is when your armpit (axilla) is used to check your temperature. A temperature measures body heat. A thermometer (there-MOM-uh-ter) is used to take the temperature in your armpit. An axillary temperature is lower than one taken in your mouth, rectum, or your ear. This is because the thermometer is not inside your body such as under your tongue. ""Why do I need to check an axillary temperature? ""An axillary temperature may be done to check for a fever. 'Fever' is a word used for a temperature that is higher than normal for the body. A fever may be a sign of illness, infection or other conditions. A normal axillary temperature is between 96.6? (35.9? C) and 98? F (36.7? C). The normal axillary temperature is usually a degree lower than the oral (by mouth) temperature. The axillary temperature may be as much as two degrees lower than the rectal temperature. Body temperature changes slightly through the day and night, and may change based on your activity. ... ""How do I use a digital thermometer? ""Wait at least 15 minutes after bathing or exercising before taking your axillary temperature. - Take the thermometer out of its holder. - Put the tip into a new throw-away plastic cover. If you do not have a cover, clean the pointed end (probe) with soap and warm water or rubbing alcohol. Rinse it with cool water. - Put the end with the covered tip securely in your armpit. Hold your arm down tightly at your side. - Keep the thermometer in your armpit until the digital thermometer beeps. - Remove the thermometer when numbers show up in the 'window'. - Read the numbers in the window. These numbers are your temperature. Add at least 1 degree to the temperature showing in the window. ..."" (URL: ) -- (f) Facility Policy Review of the facility's policy titled ""3.5 Vital Signs"" (revision date 10/01/10) revealed it was silent to how staff was to take a resident's temperature (e.g., route; device to be used; etc.). Review of the facility's document titled ""Clinical Competency Validation - Skill: Measuring Temperature, Pulse, and Respiration"" (revision date of 10/2009) revealed the steps to be taken by staff to measure and record a resident oral temperature. This document did not address how to measure a resident's axillary temperature. There was no policy or procedure available to address the difference between an axillary temperature reading and an oral temperature reading, such as whether to add 1 degree F when reading an axillary temperature or when an axillary temperature was elevated enough to require treatment with medication. -- (g) Care Plans Addressing Vital Signs A review of the resident's care plan revealed the following: (1) A problem statement related to UTIs stated: ""(Resident #28) is at risk for complications of current UTI."" (This problem statement had a ""Date Initiated"" of 11/05/10, was ""Created on"" 11/11/10, and was revised on 11/17/10.) The goal associated with this problem statement was: ""Infection will be resolved within 14 days."" (This goal had a ""Date Initiated"" of 11/17/10, was ""Created on"" 11/11/10, was revised on 11/17/10, and had a ""Target Date"" of 12/01/10.) The interventions developed to achieve this goal were: - ""Monitor vital signs and report to physician as indicated."" (This intervention had a ""Date Initiated"" of 11/05/10, was ""Created on"" 11/11/10, and was revised on 11/17/10.) - ""Administer [MEDICATION NAME] as ordered."" (This intervention had a ""Date Initiated"" of 11/17/10, was ""Created on"" 11/11/10, and was revised on 11/17/10.) There was no mention anywhere in this 13-page care plan of the need to measure Resident #28's temperature via the axilla due to an inability to obtain a temperature reading via another route (e.g., oral, rectal, tympanic). Given that the resident's standing physician orders [REDACTED]. -- (2) Another problem statement was: ""Triple lumen PICC line due to need for IV antibiotics for urosepsis."" (This problem statement had a ""Date Initiated"" of 09/23/10, was ""Created on"" 01/20/10, and was revised on 10/11/10.) The goal associated with this problem statement was: ""(Resident #28) will have no complication related to IV therapy by (sic) x 60 days."" (This goal had a ""Date Initiated"" of 09/23/10, was ""Created on"" 01/20/10, was revised on 11/17/10, and had a ""Target Date"" of 12/11/10.) One (1) intervention developed to achieve this goal was: ""Vital signs q (every) shift."" (This intervention had a ""Date Initiated"" of 01/20/10, was ""Created on"" 01/20/10, and was revised on 10/11/10.) - Review of the VSR found no evidence to reflect this resident's temperature was measured and recorded on every shift in accordance with this care plan intervention. -- 5. Fluid Balance / Hydration Status (a) Physician Orders Review of the physician's orders [REDACTED]. - ""[MEDICATION NAME] 1.5 at 85 cc (sic) hour for 20 hour cycle with 4 hours down time (sic) off at 6am (sic) on at 10 am (sic) continue with h2o (sic) flushes of 275cc (sic) every 4 hours for additional 1650ml (sic) a day. Hold if residual (sic) 100ml or over."" - ""Hand irrigate foley (sic) with 60 cc sterile H2O every 8 hours or as needed for output less than 200cc (sic)."" - ""Suprapubic cath eter (sic) check every shift for placement and function. May change cath when dysfunctional."" -- (b) Care Plan Addressing Hydration / Fluid Balance Review of his care plan revealed the following problem statement: ""I have an enteral feeding tube to meet nutritional needs due to impaired swallowing secondary to [MEDICAL CONDITION] MS."" (This problem statement had a ""Date Initiated"" of 04/30/10, was ""Created on"" 04/30/10, and was revised on 07/21/10.) Interventions associated with this problem statement included: ""Free H2O, 250ml q 4 hrs, as ordered."" (This intervention had a ""Date Initiated"" of 04/30/10 and was ""Created on"" 04/30/10.) Review of this 13-page care plan found no other problem statements, goals, or interventions addressing the resident's hydration status / fluid balance, although the resident was totally dependent on others to meet his nutrition and hydration needs. There was also no care plan developed to address the need to hand irrigate the catheter with 60 cc of sterile water if the resident's urinary output",2014-04-01
11384,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2010-12-21,157,D,,,NKSJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of records from two (2) hospitals, review of facility policies and procedures, and review of information published on the Internet related to the topics of ""fever"" and ""axillary temperature facility failed, for one (1) of five (5) sampled residents, to promptly notify the physician when the resident exhibited intermittent elevated temperatures beginning two (2) days after having completed a 3-day course of antibiotic for a urinary tract infection [MEDICAL CONDITION]. Resident #28 completed his antibiotic therapy on 11/07/10 and began having intermittent fevers on 11/09/10. Staff did not notify the physician of this until 11/16/10. The resident, who was transferred to a hospital on [DATE], was subsequently diagnosed with [REDACTED]. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. Although the assessor noted the resident had infection with a multi-drug resistant organism (MDRO), the assessor did NOT place checkmarks in the assessment to indicate the resident's active [DIAGNOSES REDACTED]. According to the State-specific section of this MDS, the resident had NOT acquired any MDRO infections since his last assessment, to include [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The assessor noted Resident #28 was alert, rarely / never able to make self understood or to understand others, with impaired short and long term memory and severely impaired cognitive skills for daily decision making. He required the extensive physical assistance of two (2) or more staff members for bed mobility, transferring, locomotion, dressing, toilet use, and personal hygiene, he was totally dependent on one (1) staff member for eating, he did not receive any nutrition through tube feeding (although elsewhere in his record was noted that he received feedings through a gastrostomy - ""PEG tube"" or ""[DEVICE]""), and he was frequently incontinent of bowel and had in place an indwelling urinary catheter (elsewhere in his record, it was noted to be a suprapubic catheter). Further review of assessment data revealed he was transferred (with return anticipated) to an acute care hospital on [DATE], and he returned to the facility on [DATE]. -- 2. Review of the resident's hospital records revealed he arrived in the emergency room (ER) of Hospital #1 on 11/17/10. Notes written by the ER nursing staff stated, ""2240 (10:40 p.m.) Pt (patient) arrives /c (with) multi layers of Blankets (sic). Hot, moist skin Red (sic) in color. ... Blankets removed. ... 11/17 (sic) 0040 (12:40 a.m. on 11/18/10) [MEDICATION NAME] (L) (left) D/C'd (discontinued) per physician, Blue (sic) tip sent to lab for culture. ..."" Documentation by the ER physician on a form titled ""Physical Exam"" identified the resident was lethargic, his abdomen was distended and tympanic, ""decubiti"" (pressure sores) were present ""multi site"", and the resident had a [MEDICATION NAME] central line with a dressing labeled ""11/9/10"". In addition to a culture of the [MEDICATION NAME] central line catheter tip, the physician ordered urine and blood cultures. The physician reviewed the results of a urine culture and sensitivity from a previous admission, found the organism previously cultured was E. coli that was positive for extended spectrum beta lactamase (which was resistant to [MEDICATION NAME] and sensitive to Imipenem), and ordered intravenous [MEDICATION NAME] and Imipenem ([MEDICATION NAME]). The [MEDICATION NAME] was started, and the [MEDICATION NAME] was sent with him (""Start [MEDICATION NAME] when [MEDICATION NAME] complete"") when he was transferred to Hospital #2 at 0350 (3:50 a.m.) on 11/18/10. The resident was transferred from Hospital #1 to Hospital #2 related to the lack of a bed at Hospital #1, and the resident a direct admit into Hospital #2's intensive care unit ""because [MEDICAL CONDITION] secondary to urinary tract infection"". The resident arrived at Hospital #2 on the early morning of 11/18/10. The resident's Hospital #2 ""History and Physical"" revealed under the heading ""History of Present Illness"": ""This is a [AGE] year-old Caucasian male with a history of end-stage [MEDICAL CONDITION], depression, chronic [MEDICAL CONDITION], gastroparesis, [MEDICAL CONDITION] bladder, [MEDICAL CONDITION] reflux disease, [MEDICAL CONDITION], and recurrent urinary tract infection who was transferred (sic) (Hospital #1) to (Hospital #2) for direct admission to (sic) intensive care unit because [MEDICAL CONDITION] secondary to urinary tract infection. ... It seems the patient used to have a recurrent urinary tract infection in the past, but the last time he was found to have a urinary tract infection and got admitted to the hospital was in early 2010. Since the placement of (sic) cystostomy tube (a suprapubic catheter) in early 2010, the patient did not get admitted to the hospital because of urinary tract infection (sic). ..."" ""In the emergency room , the patient was evaluated by the ER physician who found the patient to [MEDICAL CONDITION] with temperature 101.8 degrees, heart rate in excess of 110 per minute and also respiratory rate in excess of 24 per minutes. His white blood cell count also was high at 14,600. Because he needed to be admitted and there was no hospital bed in the (name of Hospital #1), the patient has been transferred to (name of Hospital #2). I admitted the patient to the intensive care unit for close monitoring, because of his complicated previous history and also serious hospital admission."" Under the heading ""Impressions"" were noted: ""1. High fever, secondary [MEDICAL CONDITION]. 2. Urinary tract infection. ..."" Under the heading ""Plans"" were noted: ""1. Admit to ICU. 2. Blood and urine cultures which were done in the (Hospital #1) emergency room . Will send wound culture from cystostomy (suprapubic) tube area. 3. Empiric IV antibiotics with Imipenem, [MEDICATION NAME] (sic) and [MEDICATION NAME] will be continued, which were started in the emergency room in (name of Hospital #1). 4. IV hydration will be given cautiously. 5. Will continue home medications."" The resident's Hospital #2 ""Discharge Summary"" revealed the following discharge Diagnoses: [REDACTED]. [MEDICAL CONDITION]. 2. Urinary tract infection. 3. [MEDICAL CONDITION] surrounding his suprapubic catheter and gastric tube site. 4. Catheter line associated bacteremia with Staphylococcus epidermis, all subsequent cultures negative."" Under the heading ""Hospital Course"" was noted, ""The patient was sent to (name of Hospital #1) from his nursing home for high fevers. He was found to have a highly positive urinary tract infection as well as pus surrounding his suprapubic catheter and [DEVICE] as well as some small scattered pressure sores. The patient is a known chronic quadriplegic from end-stage MS and has a history of recurrent urosepsis and ESBL positive organisms. The patient's ultimate infectious sources included a single blood culture positive for staph epidermidis, also listed from his catheter tip although I am not sure which catheter this was as it was not documented. Presumably it was some type of a central line. He also had both areas of [MEDICAL CONDITION] positive for cultures with [MEDICAL CONDITION]-resistant Staphylococcus aureus as well as pseudomonas and ESBL positive Escherichia coli. Urine culture was positive for [MEDICATION NAME] which was [MEDICATION NAME] sensitive but [MEDICATION NAME] resistant, also positive for the ESBL. Escherichia coli as well. ... The patient resolved with routine treatment of [REDACTED]. -- 3. Review of the resident's electronic medical record at the nursing facility revealed the following consecutive nursing notes: - 11/04/10 at 5:14 a.m. - ""Increased temp. of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) given vie (sic) peg tube. Will continue to monitor."" - 11/05/10 at 1:59 p.m. - ""Resident extremely sweaty (sic) temp taken 100.4ax (axillary). Contacted Dr. (name). Verbal order for [MEDICATION NAME] 1gram IM (intramuscular injection) qd (everyday) x 3 days for UTI. Will continue to monitor."" - 11/05/10 at 10:53 p.m. - ""Resident showing s/s (sign and symptoms of) illness as temp cont(inues) to rise. Tylenol via GT ([DEVICE]) given with decrease of temp at this time. ... Will continue to monitor."" ?- 11/06/10 at 9:54 p.m. - ""Temp 98.9 Axillary (sic) Resident continues on an ABT (antibiotic therapy) for UTI, no adverse reactions noted."" - 11/07/10 at 2:12 a.m. - ""Temp 97.2 axillary. Continues ABT related to UTI. ... No signs and symptoms of distress. Will monitor."" - 11/07/10 at 9:21 p.m. - ""Temp 98.1 (sic) Completed ABT today for UTI. 0 (no) adverse reactions noted."" - 11/09/10 at 3:36 a.m. - ""S/P (status [REDACTED]."" - 11/11/10 at 6:00 a.m. - ""temp (sic) 100.1 ax. tylenol (sic) 350mg (sic) per g.t. (sic) @ 0245."" - 11/11/10 at 4:36 p.m. - ""97.9 (sic) continues with tube feed of [MEDICATION NAME] ,flushes (sic) with ease. ... exhibits no signs of distress."" - 11/14/10 at 12:01 p.m. - ""VS (vital signs): 97 20 100/70 97.8. alert. Total care. Suprapubic cath patent. [DEVICE] flushed with each ... Zero signs or symptoms of distress noted. Will continue to monitor."" - 11/15/10 at 2:42 p.m. - ""Residents (sic) mothers (sic) was in today to visit ..."" - 11/16/10 at 6:57 a.m. - ""resident (sic) alert. total (sic) care.area (sic) around suprapubic cath.cleaned, (sic) temp 102.2 ax at 0500.tyleol (sic) 650mg per [DEVICE] given. resting (sic) at this time."" - 11/16/10 at 2:11 p.m. - ""Resident heard moaning from hallway (sic) Temp 100.6ax (sic). Gave tylenol (sic) 650mg via gt (sic). Called Dr. (name) (sic) verbal order given from [MEDICATION NAME] 1gram (sic) IM QD x3days (sic). Meds ordered from pharmacy. Resident resting quietly now."" - 11/17/10 at 3:34 p.m. - ""Temp 98.1ax (sic). New order [MEDICATION NAME] IV (intravenously) x3days (sic), ordered stat from pharmacy along with flushes and IV pump. [MEDICATION NAME] 1gram IV (intravenous) given via PICC at 1:30pm (sic) without difficulty. No adverse reactions noted. No s/s (signs / symptoms) IV complications noted."" - 11/17/10 at 6:01 p.m. - ""Resident moaning loudly, when asked if uncomfortable he said 'yeah'. V/S (vital signs) stable, tylenol (sic) given for apparent discomfort. GT turned off for time r/t (related to) abd (abdominal) discomfort. ... Will cont to monitor. Urinary output >200cc at this time. ABT [MEDICATION NAME] IM (sic) continues for UTI. No adverse effect noted. Fluid tolerated via GT."" - 11/17/10 at 8:28 p.m. - ""Monitoring resident frequently, no futhur (sic) moaning noted. Resting quietly. V/S remain stable, afebrile. T&P (turn and position) frequently. HOB (head of bed) ele (elevated) for comfort. Will continue to monitor."" - 11/17/10 at 9:48 p.m. - ""(Resident #28) transferred to hospital-unplanned (sic) for evaluation and treatment via ambulance to (name of Hospital #1). Physician notified of transfer. Physician called 2145 (9:45 p.m.) with info of condition change, order to send to (Hospital #1) for eval and tx (treat). Responsible party notified of transfer ..."" -- 4. Record review, including a comparison was made of documentation found in the nursing notes, in the weights and vitals summary report (VSR), and on the November 2010 MAR indicated [REDACTED] From 09/25/10 until 11/04/10, the resident had no temperatures recorded in the VSR that exceeded a pre-established threshold that triggered further assessment. Beginning on the early morning of 11/04/10, the resident had a fever of 100.6 degrees F (axillary) for which he was medicated with Tylenol 650 mg. He continued to have an elevated temperature on 11/05/10, at which time the nurse contacted the physician, who ordered the antibiotic [MEDICATION NAME] 1 gram IM everyday for three (3) days. On the telephone order, the indication for use of the [MEDICATION NAME] was ""UTI"". According to the nursing notes, the last dose of this 3-day course of [MEDICATION NAME] was administered on 11/07/10. According to the November 2010 MAR, a nurse administered Tylenol 650 mg for an elevated temperature at 6:00 p.m. on 11/09/10, although there were no corresponding entries in either then nursing notes or the VSR to state what the temperature was. Per documentation on the MAR, additional doses of Tylenol 650 mg were administered for elevated temperatures on 11/11/10 (possibly twice, although one (1) entry was illegible), 11/13/10 (twice), 11/14/10, 11/15/10, and 11/16/10 (twice). Staff did not notify the physician that Resident #28 continued to have intermittent fevers (beginning on 11/09/10) after completion of the first 3-day course of [MEDICATION NAME] on 11/07/10. Once notified of the resident's elevated temperature on 11/16/10, the physician ordered a second 3-day course of [MEDICATION NAME] 1 gram IM everyday for three (3) days for ""UTI"". The physician examined the resident on 11/16/10, recorded a [DIAGNOSES REDACTED]. -- 5. According to Medline Plus (a service of the U.S. National Library of Medicine / National Institutes of Health ), in an article titled ""Fever"": ""Fever is the temporary increase in the body's temperature in response to some disease or illness. "" ... An adult probably has a fever when the temperature is above 99 - 99.5 ?F (37.2 - 37.5 ?C), depending on the time of day. "" ... Call your doctor right away if you are an adult and you: ... - Have a fever for longer than 48 - 72 hours - Have had fevers come and go for up to a week or more, even if they are not very high - Have a serious medical illness, such as a heart problem, [MEDICAL CONDITION] cell [MEDICAL CONDITION], diabetes, [DIAGNOSES REDACTED], [MEDICAL CONDITION], or other chronic lung problems ... - Have trouble with your immune system (chronic steroid therapy, after a bone marrow or organ transplant, had spleen removed, HIV-positive, were being treated for [REDACTED]. (URL: http://www.nlm.nih.gov/medlineplus/ency/article/ 0.htm) -- 6. A review of the resident's care plan revealed the following: A problem statement related to UTIs stated: ""(Resident #28) is at risk for complications of current UTI."" (This problem statement had a ""Date Initiated"" of 11/05/10, was ""Created on"" 11/11/10, and was revised on 11/17/10.) The goal associated with this problem statement was: ""Infection will be resolved within 14 days."" (This goal had a ""Date Initiated"" of 11/17/10, was ""Created on"" 11/11/10, was revised on 11/17/10, and had a ""Target Date"" of 12/01/10.) The interventions developed to achieve this goal included: ""Monitor vital signs and report to physician as indicated."" (This intervention had a ""Date Initiated"" of 11/05/10, was ""Created on"" 11/11/10, and was revised on 11/17/10.) .",2014-04-01
11385,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2010-12-21,514,D,,,NKSJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, the facility failed to maintain clinical records for one (1) of five (5) residents (#28) in accordance with accepted professional standards and practices that are completed, accurately documented, readily accessible, and systematically organized. The facility failed to obtain and consistently record in the same place in the electronic medical record Resident #28's vital signs (e.g., temperature) every shift in accordance with his care plan related to antibiotic administration via his central line for the treatment of [REDACTED]. readings for analysis, tracking, and trending of abnormal findings. The facility also failed to record on the medication administration record (MAR) each time Tylenol was given from an elevated temperature and failed to record on the reverse side of the MAR whether the medication was effective in reducing his temperature. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his minimum data set assessment (MDS 3.0), an abbreviated quarterly assessment with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10. Further review of assessment data revealed he was transferred (with return anticipated) to an acute care hospital on [DATE], and he returned to the facility on [DATE]. -- 2. A review of the resident's electronic medical record at the nursing facility revealed a weights and vitals summary report (VSR) for the period of 10/16/10 to 11/17/10 revealed the following consecutive entries: - 10/16/10 at 3:55 a.m. - 97.4 (axilla) - 11/05/10 at 10:51 p.m. - 99.2 (axilla) - High of 99.0 exceeded - 11/05/10 at 11:30 p.m. - 101.10 (axilla) - High of 99.0 exceeded - 11/06/10 at 12:51 a.m. - 98.1 (axilla) - 11/08/10 at 3:29 a.m. - 98.7 (axilla) - 11/09/10 at 3:37 a.m. - 97.2 (tympanic) - 11/09/10 at 9:52 p.m. - 97.2 (axilla) - 11/10/10 at 2:28 a.m. - 98.3 (axilla) - 11/10/10 at 11:45 a.m. - 98.2 (axilla) - 11/11/10 at 5:55 a.m. - 100.1 (axilla) - High of 99.0 exceeded - 11/11/10 at 5:56 a.m. - 97.8 (axilla) - 11/11/10 at 10:01 p.m. - 98.2 (axilla) - 11/12/10 at 4:41 a.m. - 98.7 (axilla) - 11/13/10 at 3:52 a.m. - 99.7 (axilla) - High of 99.0 exceeded - 11/13/10 at 2:07 p.m. - 97.4 (axilla) - 11/13/10 at 9:37 p.m. - 96.7 (axilla) - 11/14/10 at 4:59 a.m. - 97.8 (axilla) - 11/14/10 at 9:48 p.m. - 97.9 (axilla) - 11/15/10 at 2:50 a.m. - 97.5 (axilla) - 11/16/10 at 4:02 a.m. - 98.4 (axilla) - 11/17/10 at 5:08 a.m. - 99.5 (axilla) - High of 99.0 exceeded - 11/17/10 at 9:52 p.m. - 101.7 (axilla) - High of 99.0 exceeded - 11/17/10 at 10:54 p.m. - 102.4 (axilla) - High of 99.0 exceeded According to the VSR, between 09/11/10 and 11/05/10, Resident #28 had only one (1) temperature reading that was flagged for review as ""High of 99.0 exceeded"". This occurred at 2:37 p.m. on 09/23/10, at which time his axillary temperature measured 99.5 degrees F. -- 3. Further review of the resident's electronic medical record at the nursing facility revealed the following consecutive nursing notes: - 10/13/10 at 5:45 p.m. - ""Temp: 98.7. zero (sic) signs or symptoms of distress (sic) will cont(inue) to monitor."" - 10/14/10 at 1:47 p.m. - ""Peg (sic) tube pulled out during care, scant amount of bleeding notes at site. Cleansed area with [MEDICATION NAME] (sic), replaced with 20Fr 15cc magna port (sic) Proper placement noted, flushes without difficulties. [MEDICATION NAME] 1.5cal (sic) running at 85cc/hr. no (sic) problems noted."" - 10/17/10 at 11:30 a.m. - ""REsident (sic) g tube (sic) flushed with ease and proper placement. 60cc (sic) of residual noted."" - 11/04/10 at 5:14 a.m. - ""Increased temp. of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) given vie (sic) peg tube. Will continue to monitor."" - 11/05/10 at 1:59 p.m. - ""Resident extremely sweaty (sic) temp taken 100.4ax (axillary). Contacted Dr. (name). Verbal order for [MEDICATION NAME] 1gram IM (intramuscular injection) qd (everyday) x 3 days for UTI. Will continue to monitor."" - 11/05/10 at 10:53 p.m. - ""Resident showing s/s (sign and symptoms of) illness as temp cont(inues) to rise. Tylenol via GT ([DEVICE]) given with decrease of temp at this time. ... Will continue to monitor."" ?- 11/06/10 at 9:54 p.m. - ""Temp 98.9 Axillary (sic) Resident continues on an ABT (antibiotic therapy) for UTI, no adverse reactions noted."" - 11/07/10 at 2:12 a.m. - ""Temp 97.2 axillary. Continues ABT related to UTI. ... No signs and symptoms of distress. Will monitor."" - 11/07/10 at 9:21 p.m. - ""Temp 98.1 (sic) Completed ABT today for UTI. 0 (no) adverse reactions noted."" - 11/09/10 at 3:36 a.m. - ""S/P (status [REDACTED]."" - 11/11/10 at 6:00 a.m. - ""temp (sic) 100.1 ax. tylenol (sic) 350mg (sic) per g.t. (sic) @ 0245."" - 11/11/10 at 4:36 p.m. - ""97.9 (sic) continues with tube feed of [MEDICATION NAME] ,flushes (sic) with ease. ... exhibits no signs of distress."" - 11/14/10 at 12:01 p.m. - ""VS (vital signs): 97 20 100/70 97.8. alert. Total care. Suprapubic cath patent. [DEVICE] flushed with each ... Zero signs or symptoms of distress noted. Will continue to monitor."" - 11/15/10 at 2:42 p.m. - ""Residents (sic) mothers (sic) was in today to visit ..."" - 11/16/10 at 6:57 a.m. - ""resident (sic) alert. total (sic) care.area (sic) around suprapubic cath.cleaned, (sic) temp 102.2 ax at 0500.tyleol (sic) 650mg per [DEVICE] given. resting (sic) at this time."" - 11/16/10 at 2:11 p.m. - ""Resident heard moaning from hallway (sic) Temp 100.6ax (sic). Gave tylenol (sic) 650mg via gt (sic). Called Dr. (name) (sic) verbal order given from [MEDICATION NAME] 1gram (sic) IM QD x3days (sic). Meds ordered from pharmacy. Resident resting quietly now."" - 11/17/10 at 3:34 p.m. - ""Temp 98.1ax (sic). New order [MEDICATION NAME] IV (intravenously) x3days (sic), ordered stat from pharmacy along with flushes and IV pump. [MEDICATION NAME] 1gram IV (intravenous) given via PICC at 1:30pm (sic) without difficulty. No adverse reactions noted. No s/s (signs / symptoms) IV complications noted."" - 11/17/10 at 6:01 p.m. - ""Resident moaning loudly, when asked if uncomfortable he said 'yeah'. V/S (vital signs) stable, tylenol (sic) given for apparent discomfort. GT turned off for time r/t (related to) abd (abdominal) discomfort. ... Will cont to monitor. Urinary output >200cc at this time. ABT [MEDICATION NAME] IM (sic) continues for UTI. No adverse effect noted. Fluid tolerated via GT."" - 11/17/10 at 8:28 p.m. - ""Monitoring resident frequently, no futhur (sic) moaning noted. Resting quietly. V/S remain stable, afebrile. T&P (turn and position) frequently. HOB (head of bed) ele (elevated) for comfort. Will continue to monitor."" - 11/17/10 at 9:48 p.m. - ""(Resident #28) transferred to hospital-unplanned (sic) for evaluation and treatment via ambulance to (name of Hospital #1). Physician notified of transfer. Physician called 2145 (9:45 p.m.) with info of condition change, order to send to (Hospital #1) for eval and tx (treat). Responsible party notified of transfer ..."" -- 4. Review of the resident's November 2010 MAR revealed staff initialed having administered ""Tylenol 650 mg via GT ([DEVICE]) for temp > 101 Q 4 hours PRN (as needed)"" to Resident #28 on the following dates: - 11/05/10 at 11:45 p.m. - 11/09/10 at 6:00 p.m. - 11/11/10 at 2:45 a.m. - 11/11/10 (this second entry on 11/11/10 is illegible) - 11/13/10 at 2:30 a.m. - 11/13/10 at 5:00 p.m. - 11/14/10 at 5:00 p.m. - 11/15/10 at 8:00 p.m. - 11/16/10 at 5:00 a.m. - 11/16/10 at 11:00 a.m. - 11/17/10 at 5:45 p.m. -- 5. Record review, including a comparison was made of documentation found in the nursing notes, in the VSR, and on the November 2010 MAR related to the administration of Tylenol for elevated temperatures, revealed the following: (a) Not all temperatures were recorded in a single location in the resident's medical record where the user could access and review all temperature readings for analysis, tracking, and trending. On thirteen (13) occasions between 11/04/10 and 11/17/10, temperatures were recorded in the nursing notes (NN) and/or nurses initialed the MAR to indicate Tylenol was given for an elevated temperature, but no corresponding entry of a temperature reading was found on the VSR: - NN on 11/04/10 at 5:14 a.m. - ""Increased temp. of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) ..."" - MAR on 11/09/10 at 6:00 p.m. - Tylenol was given for elevated temperature - NN on 11/05/10 at 1:59 p.m. - ""Resident extremely sweaty (sic) temp taken 100.4ax (axillary). ..."" - MAR on 11/11/10 at 2:45 a.m. - Tylenol was given for elevated temperature. (A corresponding entry was also found in a NN at 6:00 a.m. on 11/11/10 as follows: ""temp (sic) 100.1 ax. tylenol (sic) 350mg (sic) per g.t. (sic) @ 0245."") - MAR on 11/13/10 at 2:30 a.m. - Tylenol was given for elevated temperature - MAR on 11/13/10 at 5:00 p.m. - Tylenol was given for elevated temperature - MAR on 11/14/10 at 5:00 p.m. - Tylenol was given for elevated temperature - MAR on 11/15/10 at 8:00 p.m. - Tylenol was given for elevated temperature - NN on 11/16/10 at 6:57 a.m. - "" ... temp 102.2 ax at 0500.tyleol (sic) 650mg per [DEVICE] given. ..."" (A corresponding entry was also found on the MAR for 11/16/10 at 5:00 a.m.) - NN on 11/16/10 at 2:11 p.m. - "" ... Temp 100.6ax (sic). Gave tylenol (sic) 650mg via gt (sic). ..."" - MAR on 11/16/10 at 11:00 a.m. - Tylenol was given for elevated temperature - NN on 11/17/10 at 3:34 p.m. - ""Temp 98.1ax (sic). ..."" - MAR on 11/17/10 at 5:45 p.m. - Tylenol was given for elevated temperature - (b) Not all instances when Tylenol was administered were recorded on the MAR. On one (1) occasion between 11/04/10 and 11/17/10, a nurse recorded (in the nursing notes) having administered Tylenol to Resident #28, for which there was no corresponding entry in the MAR: - NN on 11/04/10 at 5:14 a.m. - ""Increased temp. (temperature) of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) ..."" - (c) One (1) entry on the MAR (on 11/11/10) was illegible; therefore, it could not be ascertained whether a second dose of Tylenol was given or, if a second dose was given, at what time it was administered. - (d) No documentation was found on the reverse side of the MAR, when Tylenol was given for an elevated temperature, of an assessment of the effectiveness of the PRN Tylenol in reducing the resident's temperature after administration.",2014-04-01
11386,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2010-12-21,282,D,,,NKSJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of hospital records, policy review, and staff interview, the facility failed to provide services to one (1) of five (5) sampled residents in accordance with the resident's comprehensive plan of care including physician orders, with respect to: monitoring vital signs; providing free water flushes as ordered; monitoring the resident's urinary output to ascertain whether it was necessary to irrigate the resident's suprapubic catheter; monitoring central line and ostomy sites for signs of infection; and providing dressing changes to the central line site as ordered. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. Although the assessor noted the resident had infection with a multi-drug resistant organism (MDRO), the assessor did NOT place checkmarks in the assessment to indicate the resident's active [DIAGNOSES REDACTED]. According to the State-specific section of this MDS, the resident had NOT acquired any MDRO infections since his last assessment, to include [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The assessor noted Resident #28 was alert, rarely / never able to make self understood or to understand others, with impaired short and long term memory and severely impaired cognitive skills for daily decision making. He required the extensive physical assistance of two (2) or more staff members for bed mobility, transferring, locomotion, dressing, toilet use, and personal hygiene, he was totally dependent on one (1) staff member for eating, he did not receive any nutrition through tube feeding (although elsewhere in his record was noted that he received feedings through a PEG tube), and he was frequently incontinent of bowel and had in place an indwelling urinary catheter (elsewhere in his record, it was noted to be a suprapubic catheter). Further review of assessment data revealed he was transferred (with return anticipated) to an acute care hospital on [DATE], and he returned to the facility on [DATE]. -- 2. Review of the resident's hospital records revealed he arrived in the emergency room (ER) of Hospital #1 on 11/17/10. Notes written by the ER nursing staff stated, ""2240 (10:40 p.m.) Pt (patient) arrives /c (with) multi layers of Blankets (sic). Hot, moist skin Red (sic) in color. ... Blankets removed. ... 11/17 (sic) 0040 (12:40 a.m. on 11/18/10) [MEDICATION NAME] (L) (left) D/C'd (discontinued) per physician, Blue (sic) tip sent to lab for culture. ..."" Documentation by the ER physician on a form titled ""Physical Exam"" identified the resident was lethargic, his abdomen was distended and tympanic, ""decubiti"" (pressure sores) were present ""multi site"", and the resident had a [MEDICATION NAME] central line with a dressing labeled ""11/9/10"". In addition to a culture of the [MEDICATION NAME] central line catheter tip, the physician ordered urine and blood cultures. The physician reviewed the results of a urine culture and sensitivity from a previous admission, found the organism previously cultured was E. coli that was positive for extended spectrum beta lactamase (which was resistant to [MEDICATION NAME] and sensitive to Imipenem), and ordered intravenous [MEDICATION NAME] and Imipenem ([MEDICATION NAME]). The [MEDICATION NAME] was started, and the [MEDICATION NAME] was sent with him (""Start [MEDICATION NAME] when [MEDICATION NAME] complete"") when he was transferred to Hospital #2 at 0350 (3:50 a.m.) on 11/18/10. The resident was transferred from Hospital #1 to Hospital #2 related to the lack of a bed at Hospital #1, and the resident a direct admit into Hospital #2's intensive care unit ""because [MEDICAL CONDITION] secondary to urinary tract infection"". The resident arrived at Hospital #2 on the early morning of 11/18/10. -- The resident's Hospital #2 ""Discharge Summary"" revealed the following discharge Diagnoses: [REDACTED]. [MEDICAL CONDITION]. 2. Urinary tract infection. 3. [MEDICAL CONDITION] surrounding his suprapubic catheter and gastric tube site. 4. Catheter line associated bacteremia with Staphylococcus epidermis, all subsequent cultures negative."" Under the heading ""Hospital Course"" was noted, ""The patient was sent to (name of Hospital #1) from his nursing home for high fevers. He was found to have a highly positive urinary tract infection as well as pus surrounding his suprapubic catheter and [DEVICE] as well as some small scattered pressure sores. The patient is a known chronic quadriplegic from end-stage MS and has a history of recurrent urosepsis and ESBL positive organisms. The patient's ultimate infectious sources included a single blood culture positive for staph epidermidis, also listed from his catheter tip although I am not sure which catheter this was as it was not documented. Presumably it was some type of a central line. He also had both areas of [MEDICAL CONDITION] positive for cultures with [MEDICAL CONDITION]-resistant Staphylococcus aureus as well as pseudomonas and ESBL positive Escherichia coli. Urine culture was positive for [MEDICATION NAME] which was [MEDICATION NAME] sensitive but [MEDICATION NAME] resistant, also positive for the ESBL. Escherichia coli as well. ... The patient resolved with routine treatment of [REDACTED]. -- 3. Review of the resident ' s care plan revealed the following: (a) A problem statement related to UTIs stated: ""(Resident #28) is at risk for complications of current UTI."" (This problem statement had a ""Date Initiated"" of 11/05/10, was ""Created on"" 11/11/10, and was revised on 11/17/10.) The goal associated with this problem statement was: ""Infection will be resolved within 14 days."" (This goal had a ""Date Initiated"" of 11/17/10, was ""Created on"" 11/11/10, was revised on 11/17/10, and had a ""Target Date"" of 12/01/10.) The interventions developed to achieve this goal were: - ""Monitor vital signs and report to physician as indicated."" (This intervention had a ""Date Initiated"" of 11/05/10, was ""Created on"" 11/11/10, and was revised on 11/17/10.) - ""Administer [MEDICATION NAME] as ordered."" (This intervention had a ""Date Initiated"" of 11/17/10, was ""Created on"" 11/11/10, and was revised on 11/17/10.) There was no mention anywhere in this 13-page care plan of the need to measure Resident #28's temperature via the axilla due to an inability to obtain a temperature reading via another route (e.g., oral, rectal, tympanic). Given that the resident's standing physician orders [REDACTED]. -- (b) Another problem statement was: ""Triple lumen PICC line due to need for IV antibiotics for urosepsis."" (This problem statement had a ""Date Initiated"" of 09/23/10, was ""Created on"" 01/20/10, and was revised on 10/11/10.) The goal associated with this problem statement was: ""(Resident #28) will have no complication related to IV therapy by (sic) x 60 days."" (This goal had a ""Date Initiated"" of 09/23/10, was ""Created on"" 01/20/10, was revised on 11/17/10, and had a ""Target Date"" of 12/11/10.) One (1) intervention developed to achieve this goal was: ""Vital signs q (every) shift."" (This intervention had a ""Date Initiated"" of 01/20/10, was ""Created on"" 01/20/10, and was revised on 10/11/10.) - Review of the weights and vitals summary report found no evidence to reflect this resident's temperature was measured and recorded on every shift in accordance with this care plan intervention. -- 4. Review of the Enteral Protocol form for November 2010 revealed an order for [REDACTED]. Total Vol: ___ (left blank) ML/24 hours."" Beside this order was a series of blocks where the nurse was to initial having provided 275 cc of water at the following intervals daily: 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., 10:00 p.m., and 2:00 a.m. Initials were absent for a total of twenty-one (21) out of one hundred (100) possible flushes between 6:00 a.m. on 11/01/10 and 6:00 p.m. on 11/17/10. There was no evidence to reflect the additional free water flushes of 275 cc were provided as ordered for the following dates and times: - On 11/01/10 at 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10:00 p.m. - On 11/02/10 at 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., 10:00 p.m., and 2:00 a.m. - On 11/03/10 at 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10:00 p.m. - On 11/04/10 at 6:00 a.m., 10:00 a.m., and 2:00 a.m. - On 11/05/10 at 6:00 p.m. and 10:00 p.m. - On 11/15/10 at 6:00 p.m. and 10:00 p.m. -- Review of the treatment administration record (TAR) for November 2010 revealed an order for [REDACTED]. output was less than 200 cc. None of these blocks was initialed, even though one (1) nursing note, dated 11/17/10 at 6:01 p.m., specifically stated, "" ...Urinary output >200cc at this time."" Review of the resident's ""Bedside Intake and Output Records"" for the period of 11/01/10 through 11/17/10 revealed the following information regarding the resident's urinary output per 8-hour shift for the 11:00 p.m. to 7:00 a.m. (11-7), 7:00 a.m. to 3:00 p.m. (7-3), and 3:00 p.m. to 11:00 p.m. (3-11) shifts: Date - 11-7 - 7-3 - 3-11 = 24-hour total 11/01/10 - 400 cc - (blank) - (blank) = 400 cc 11/02/10 - 350 cc - (blank) - (blank) = 350 cc 11/03/10 - (blank) - (blank) - (blank) = 0 cc 11/04/10 - 450 cc - (blank) - (blank) = 450 cc 11/05/10 - 600 cc - (blank) - (blank) = 600 cc 11/06/10 - 800 cc - (blank) - (blank) = 800 cc 11/07/10 - 700 cc - (blank) - (blank) = 700 cc 11/08/10 - 450 cc - (blank) - (blank) = 450 cc 11/09/10 - no record available 11/10/10 - no record available 11/11/10 - 225 cc - (blank) - (blank) = 225 cc 11/12/10 - 450 cc - (blank) - 325 cc = 775 cc 11/13/10 - no record available 11/14/10 - no record available 11/15/10 - 250 cc - (blank) - (blank) = 250 cc 11/16/10 - no record available 11/17/10 - 350 cc - (blank) - (blank) = 350 cc No additional documentation was found elsewhere in the resident's record to reflect staff was monitoring and recording his urinary output during each 8-hour shift, to identify the need for the 60 cc flushes or to assess the resident's hydration status. -- An interview with the ADON, on 11/21/10 at 9:30 a.m., revealed the resident required more free water added to the gastric tube, because of the intermittent fevers during the month of November. -- 5. Review of a facility table titled ""Infusion Maintenance Table"" (with a revision date of 04/01/10), revealed dressing changes for non-tunneled central venous access devices (including [MEDICATION NAME] central lines) are to be performed twenty-four (24) hours after insertion, then weekly and PRN. (It should be noted that the facility used ""PICC line"" in documentation prior to his return to the facility on [DATE] to describe what a [MEDICATION NAME] central line.) -- Further review of the resident ' s care revealed: One (1) problem statement said: ""Triple lumen PICC line due to need for IV antibiotics for urosepsis."" (This problem statement had a ""Date Initiated"" of 09/23/10, was ""Created on"" 01/20/10, and was revised on 10/11/10.) The goal associated with this problem statement was: ""(Resident #28) will have no complication related to IV therapy by (sic) x 60 days."" (This goal had a ""Date Initiated"" of 09/23/10, was ""Created on"" 01/20/10, was revised on 11/17/10, and had a ""Target Date"" of 12/11/10.) One (1) intervention developed to achieve this goal was: ""Sterile dressing change per policy and prn (as needed)."" (This intervention had a ""Date Initiated"" of 01/20/10, was ""Created on"" 01/20/10, and was revised on 10/11/10.) - Review of Resident #28's treatment sheet, used for recording care provided to central-line catheters, found it was marked to indicate scheduled dressing changes were to be completed on 11/02/10, 11/09/10, and 11/16/10. The dressing change scheduled for 11/16/10 was not initialed by a nurse to indicate it had been completed, in accordance with facility policy and the resident's care plan intervention. Another intervention developed to achieve this goal was: ""Inspect site for signs of inflammation, phlebitis, or infiltration q shift."" (This intervention had a ""Date Initiated"" of 01/20/10, was ""Created on"" 01/20/10, and was revised on 10/11/10.) - Review of the resident's treatment records and nursing notes found no documented evidence to reflect licensed nursing staff was inspecting the site of the central line for signs and symptoms of infection in accordance with this care plan intervention. -- Another problem statement was: ""I have an enteral feeding tube to meet nutritional needs due to impaired swallowing secondary to [MEDICAL CONDITION] MS."" (This problem statement had a ""Date Initiated"" of 04/30/10, was ""Created on"" 04/30/10, and was revised on 07/21/10.) Interventions associated with this problem statement included: ""Monitor skin around PEG tube site,skin (sic) care and dressing as ordered."" (This intervention had a ""Date Initiated"" of 04/30/10 and was ""Created on"" 04/30/10.) - Review of the monthly recapitulation of physician's orders [REDACTED]. Review of the resident's treatment records and nursing notes found no documented evidence to reflect licensed nursing staff was routinely inspecting the site for signs or infection. -- An interview with the assistant director of nursing (ADON - Employee #9), on 12/20/10 at 4:00 p.m., confirmed the form utilized by staff to documented central line dressing changes was not initialed on 11/16/10, which was the date the dressing was due to be changed. She further stated the nursing staff apparently did not change the dressing. -- According to the Hospital #2 ""Discharge Summary"", when the resident was evaluated in the hospital on the early morning of 11/18/10, the ER physician found pus surrounding his suprapubic catheter and [DEVICE], and his [MEDICATION NAME] catheter tip tested positive for Staphylococcus epidermidis. .",2014-04-01
11387,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2010-12-21,279,D,,,NKSJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of records from two (2) hospitals, and staff interview, the facility failed, for one (1) of five (5) sampled residents, to develop a care plan to ensure a resident with a gastrostomy feeding tube and a suprapubic catheter, who had a history of [REDACTED]. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Resident Assessment Data Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. Although the assessor noted the resident had infection with a multi-drug resistant organism (MDRO), the assessor did NOT place checkmarks in the assessment to indicate the resident's active [DIAGNOSES REDACTED]. According to the State-specific section of this MDS, the resident had NOT acquired any MDRO infections since his last assessment, to include [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The assessor noted Resident #28 was alert, rarely / never able to make self understood or to understand others, with impaired short and long term memory and severely impaired cognitive skills for daily decision making. He required the extensive physical assistance of two (2) or more staff members for bed mobility, transferring, locomotion, dressing, toilet use, and personal hygiene, he was totally dependent on one (1) staff member for eating, he did NOT receive any nutrition through tube feeding (although elsewhere in his record was noted that he received feedings through a gastrostomy - ""PEG tube"" or ""[DEVICE]""), and he was frequently incontinent of bowel and had in place an indwelling urinary catheter (elsewhere in his record, it was noted to be a suprapubic catheter). Further review of assessment data revealed he was transferred (with return anticipated) to an acute care hospital on [DATE], and he returned to the facility on [DATE]. -- 2. Hospital #1 Records Review of the resident's hospital records revealed he arrived in the emergency room (ER) of Hospital #1 on 11/17/10. Notes written by the ER nursing staff stated, ""2240 (10:40 p.m.) Pt (patient) arrives /c (with) multi layers of Blankets (sic). Hot, moist skin Red (sic) in color. ... 11/17 (sic) 0040 (12:40 a.m. on 11/18/10) [MEDICATION NAME] (L) (left) D/C'd (discontinued) per physician, Blue (sic) tip sent to lab for culture. ..."" Review of the form titled ""ED Nursing Record - Adult Male - PRIMARY ASSESSMENT"", in the section titled ""EENT"" (ears, eyes, nose, throat) was written: ""Dried oral secretions (sic) oral membrane"". In the section titled ""Skin"" were circled the words ""diaphoresis"" and ""hot"". In the section titled ""Cardiovascular"" was written (next to the printed word ""[MEDICAL CONDITION]"") ""mild Bilat(eral) leg & arm"". Above the nurse's signature was written: ""hands / fingers swelled (sic) ..."" Documentation on the form titled ""ED Nursing Record - Adult Male - General Documentation"", under the heading ""I & O"" (fluid intake and output), noted the resident received 1000 cc of fluid (elsewhere identified as normal sterile saline - NSS) and voided 50 cc of urine while in the ER of Hospital #1. Documentation by the ER physician on a form titled ""Physical Exam"" identified the resident was lethargic and ""Patient much more alert /p (after) NS (normal saline) Bolus."" The resident was transferred from Hospital #1 to Hospital #2 related to the lack of a bed at Hospital #1, and the resident a direct admit into Hospital #2's intensive care unit ""because [MEDICAL CONDITION] secondary to urinary tract infection"". The resident arrived at Hospital #2 on the early morning of 11/18/10. -- 3. Hospital #2 Records The resident's Hospital #2 ""Discharge Summary"" revealed the following discharge Diagnoses: [REDACTED]. [MEDICAL CONDITION]. 2. Urinary tract infection. 3. [MEDICAL CONDITION] surrounding his suprapubic catheter and gastric tube site. 4. Catheter line associated bacteremia with Staphylococcus epidermis, all subsequent cultures negative."" Under the heading ""Hospital Course"" was noted, ""The patient was sent to (name of Hospital #1) from his nursing home for high fevers. He was found to have a highly positive urinary tract infection as well as pus surrounding his suprapubic catheter and [DEVICE] as well as some small scattered pressure sores. The patient is a known chronic quadriplegic from end-stage MS and has a history of recurrent urosepsis and ESBL positive organisms. The patient's ultimate infectious sources included a single blood culture positive for staph epidermidis ... He also had both areas of [MEDICAL CONDITION] positive for cultures with [MEDICAL CONDITION]-resistant Staphylococcus aureus as well as pseudomonas and ESBL positive Escherichia coli. Urine culture was positive for [MEDICATION NAME] which was [MEDICATION NAME] sensitive but [MEDICATION NAME] resistant, also positive for the ESBL. Escherichia coli as well. ... The patient resolved with routine treatment of [REDACTED]. -- 4. Record review, including a comparison was made of documentation found in the nursing notes, in the weights and vitals summary report (VSR), and on the November 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - Beginning on the early morning of 11/04/10, the resident had a fever of 100.6 degrees F (axillary) for which he was medicated with Tylenol 650 mg. He continued to have an elevated temperature on 11/05/10, at which time the nurse contacted the physician, who ordered the antibiotic [MEDICATION NAME] 1 gram IM everyday for three (3) days. On the telephone order, the indication for use of the [MEDICATION NAME] was ""UTI"". - According to the nursing notes, the last dose of this 3-day course of [MEDICATION NAME] was administered on 11/07/10. According to the November 2010 MAR, a nurse administered Tylenol 650 mg for an elevated temperature at 6:00 p.m. on 11/09/10, although there were no corresponding entries in either then nursing notes or the VSR to state what the temperature was. Per documentation on the MAR, additional doses of Tylenol 650 mg were administered for elevated temperatures on 11/11/10 (possibly twice, although one (1) entry was illegible), 11/13/10 (twice), 11/14/10, 11/15/10, and 11/16/10 (twice). - Resident #28 continued to have intermittent fevers (beginning on 11/09/10) after completion of the first 3-day course of [MEDICATION NAME] on 11/07/10. Once notified of the resident's elevated temperature on 11/16/10, the physician ordered a second 3-day course of [MEDICATION NAME] 1 gram IM everyday for three (3) days for ""UTI"". The physician examined the resident on 11/16/10, recorded a [DIAGNOSES REDACTED]. -- 5. Fluid Balance and Monitoring Urinary Output (a) Review of the physician's orders [REDACTED]. - ""[MEDICATION NAME] 1.5 at 85 cc (sic) hour for 20 hour cycle with 4 hours down time (sic) off at 6am (sic) on at 10 am (sic) continue with h2o (sic) flushes of 275cc (sic) every 4 hours for additional 1650ml (sic) a day. Hold if residual (sic) 100ml or over."" - ""Hand irrigate foley (sic) with 60 cc sterile H2O every 8 hours or as needed for output less than 200cc (sic)."" -- (b) Review of his care plan revealed the following problem statement: ""I have an enteral feeding tube to meet nutritional needs due to impaired swallowing secondary to [MEDICAL CONDITION] MS."" (This problem statement had a ""Date Initiated"" of 04/30/10, was ""Created on"" 04/30/10, and was revised on 07/21/10.) Interventions associated with this problem statement included: ""Free H2O, 250ml q 4 hrs, as ordered."" (This intervention had a ""Date Initiated"" of 04/30/10 and was ""Created on"" 04/30/10.) Review of this 13-page care plan found no other problem statements, goals, or interventions addressing the assessment and/or maintenance of the resident's hydration status / fluid balance, although the resident was totally dependent on others to meet his nutrition and hydration needs. There was no acute care plan to address the resident's needs for additional free water flushes related to his intermittent fevers. There was also no care plan developed to address the need to hand irrigate the catheter with 60 cc of sterile water if the resident's urinary output was less than 200 cc in an 8-hour shift (although there was a physician's orders [REDACTED]. -- (c) An interview with the ADON, on 11/21/10 at 9:30 a.m., revealed the resident required more free water added to the gastric tube, because of the intermittent fevers during the month of November. .",2014-04-01
11388,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2010-12-21,281,D,,,NKSJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of hospital records, review of information published on the Internet related to the topics of ""fever"" and ""axillary temperature"", and policy review, the facility failed to provide services that meet professional standards of quality for one (1) of five (5) sampled residents (#28). Resident #28, who had a gastrostomy feeding tube and a suprapubic catheter and who had a personal history of urinary tract infections, exhibited an elevated temperature beginning on 11/04/10. On 11/05/10, staff contacted the physician, who ordered a 3-day course of antibiotics ([MEDICATION NAME]) via intramuscular injection (IM). Two (2) days after this first course of antibiotics ended, the resident began (on 11/09/10) to exhibit intermittent elevated temperatures; however, the staff did not promptly notify the physician of this. These temperatures were taken via axilla, which is usually 1 degree Fahrenheit (F) below a temperature taken orally; the temperatures were not monitored at the frequency specified in the resident's care plan; they were not consistently recorded in the same place in the medical record for ready access for analysis, tracking, and trending; and the staff did not always medicate with Tylenol when indicated. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. Although the assessor noted the resident had infection with a multi-drug resistant organism (MDRO), the assessor did NOT place checkmarks in the assessment to indicate the resident's active [DIAGNOSES REDACTED]. According to the State-specific section of this MDS, the resident had NOT acquired any MDRO infections since his last assessment, to include [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The assessor noted Resident #28 was alert, rarely / never able to make self understood or to understand others, with impaired short and long term memory and severely impaired cognitive skills for daily decision making. He required the extensive physical assistance of two (2) or more staff members for bed mobility, transferring, locomotion, dressing, toilet use, and personal hygiene, he was totally dependent on one (1) staff member for eating, he did not receive any nutrition through tube feeding (although elsewhere in his record was noted that he received feedings through a gastrostomy - "" PEG tube "" or "" [DEVICE] "" ), and he was frequently incontinent of bowel and had in place an indwelling urinary catheter (elsewhere in his record, it was noted to be a suprapubic catheter). Further review of assessment data revealed he was transferred (with return anticipated) to an acute care hospital on [DATE], and he returned to the facility on [DATE]. -- 2. Review of the resident's hospital records revealed he arrived in the emergency room (ER) of Hospital #1 on 11/17/10. Notes written by the ER nursing staff stated, ""2240 (10:40 p.m.) Pt (patient) arrives /c (with) multi layers of Blankets (sic). Hot, moist skin Red (sic) in color. ... Blankets removed. ... 11/17 (sic) 0040 (12:40 a.m. on 11/18/10) [MEDICATION NAME] (L) (left) D/C'd (discontinued) per physician, Blue (sic) tip sent to lab for culture. ..."" The resident was transferred from Hospital #1 to Hospital #2 related to the lack of a bed at Hospital #1, and the resident a direct admit into Hospital #2's intensive care unit ""because [MEDICAL CONDITION] secondary to urinary tract infection"". The resident arrived at Hospital #2 on the early morning of 11/18/10. - The resident's Hospital #2 ""Discharge Summary"" revealed the following discharge Diagnoses: [REDACTED]. [MEDICAL CONDITION]. 2. Urinary tract infection. 3. [MEDICAL CONDITION] surrounding his suprapubic catheter and gastric tube site. 4. Catheter line associated bacteremia with Staphylococcus epidermis, all subsequent cultures negative."" Under the heading ""Hospital Course"" was noted, ""The patient was sent to (name of Hospital #1) from his nursing home for high fevers. He was found to have a highly positive urinary tract infection as well as pus surrounding his suprapubic catheter and [DEVICE] as well as some small scattered pressure sores. The patient is a known chronic quadriplegic from end-stage MS and has a history of recurrent urosepsis and ESBL positive organisms. The patient's ultimate infectious sources included a single blood culture positive for staph epidermidis, also listed from his catheter tip although I am not sure which catheter this was as it was not documented. Presumably it was some type of a central line. He also had both areas of [MEDICAL CONDITION] positive for cultures with [MEDICAL CONDITION]-resistant Staphylococcus aureus as well as pseudomonas and ESBL positive Escherichia coli. Urine culture was positive for [MEDICATION NAME] which was [MEDICATION NAME] sensitive but [MEDICATION NAME] resistant, also positive for the ESBL. Escherichia coli as well. ... The patient resolved with routine treatment of [REDACTED]. -- 3. Record review, including a comparison was made of documentation found in the nursing notes, in the weights and vitals summary report (VSR), and on the November 2010 MAR related to the administration of Tylenol for elevated temperatures, revealed the following: (a) From 09/25/10 until 11/04/10, the resident had no temperatures recorded in the VSR that exceeded a pre-established threshold that triggered further assessment. Beginning on the early morning of 11/04/10, the resident had a fever of 100.6 degrees F (axillary) for which he was medicated with Tylenol 650 mg. He continued to have an elevated temperature on 11/05/10, at which time the nurse contacted the physician, who ordered the antibiotic [MEDICATION NAME] 1 gram IM everyday for three (3) days. On the telephone order, the indication for use of the [MEDICATION NAME] was ""UTI"". According to the nursing notes, the last dose of this 3-day course of [MEDICATION NAME] was administered on 11/07/10. According to the November 2010 MAR, a nurse administered Tylenol 650 mg for an elevated temperature at 6:00 p.m. on 11/09/10, although there were no corresponding entries in either then nursing notes or the VSR to state what the temperature was. Per documentation on the MAR, additional doses of Tylenol 650 mg were administered for elevated temperatures on 11/11/10 (possibly twice, although one (1) entry was illegible), 11/13/10 (twice), 11/14/10, 11/15/10, and 11/16/10 (twice). Staff did not notify the physician that Resident #28 continued to have intermittent fevers (beginning on 11/09/10) after completion of the first 3-day course of [MEDICATION NAME] on 11/07/10. Once notified of the resident's elevated temperature on 11/16/10, the physician ordered a second 3-day course of [MEDICATION NAME] 1 gram IM everyday for three (3) days for ""UTI"". The physician examined the resident on 11/16/10, recorded a [DIAGNOSES REDACTED]. -- (b) Not all temperatures were recorded in a single location in the resident's medical record where the user could access and review all temperature readings for analysis, tracking, and trending. On thirteen (13) occasions between 11/04/10 and 11/17/10, temperatures were recorded in the nursing notes (NN) and/or nurses initialed the MAR (to indicate Tylenol was given for an elevated temperature), but no corresponding entry of a temperature reading was found on the VSR: - NN on 11/04/10 at 5:14 a.m. - ""Increased temp. of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) ..."" - MAR on 11/09/10 at 6:00 p.m. - Tylenol was given for elevated temperature - NN on 11/05/10 at 1:59 p.m. - ""Resident extremely sweaty (sic) temp taken 100.4ax (axillary). ..."" - MAR on 11/11/10 at 2:45 a.m. - Tylenol was given for elevated temperature. (A corresponding entry was also found in a NN at 6:00 a.m. on 11/11/10 as follows: ""temp (sic) 100.1 ax. tylenol (sic) 350mg (sic) per g.t. (sic) @ 0245."") - MAR on 11/13/10 at 2:30 a.m. - Tylenol was given for elevated temperature - MAR on 11/13/10 at 5:00 p.m. - Tylenol was given for elevated temperature - MAR on 11/14/10 at 5:00 p.m. - Tylenol was given for elevated temperature - MAR on 11/15/10 at 8:00 p.m. - Tylenol was given for elevated temperature - NN on 11/16/10 at 6:57 a.m. - ""... temp 102.2 ax at 0500.tyleol (sic) 650mg per [DEVICE] given. ..."" (A corresponding entry was also found on the MAR for 11/16/10 at 5:00 a.m.) - NN on 11/16/10 at 2:11 p.m. - ""... Temp 100.6ax (sic). Gave tylenol (sic) 650mg via gt (sic). ..."" - MAR on 11/16/10 at 11:00 a.m. - Tylenol was given for elevated temperature - NN on 11/17/10 at 3:34 p.m. - ""Temp 98.1ax (sic). ..."" - MAR on 11/17/10 at 5:45 p.m. - Tylenol was given for elevated temperature -- (c) Two (2) instances of elevated temperatures (greater than 100.0 degrees F axillary, which would be equivalent to 101 degrees F orally), which were recorded either in the VSR or NN, were not treated with Tylenol in accordance with standing orders: - NN on 11/05/10 at 1:59 p.m. - ""Resident extremely sweaty (sic) temp taken 100.4ax (axillary). ..."" - VSR on 11/17/10 at 9:52 p.m. - 101.7 (axilla) -- (d) Not all instances when Tylenol was administered were recorded on the MAR. On one (1) occasion between 11/04/10 and 11/17/10, a nurse recorded (in the nursing notes) having administered Tylenol to Resident #28, for which there was no corresponding entry in the MAR: - NN on 11/04/10 at 5:14 a.m. - ""Increased temp. (temperature) of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) ..."" -- (e) One (1) entry on the MAR (on 11/11/10) was illegible; therefore, it could not be ascertained whether a second dose of Tylenol was given or, if a second dose was given, at what time it was administered. -- (f) No documentation was found on the reverse side of the MAR, when Tylenol was given for an elevated temperature, of an assessment of the effectiveness of the PRN Tylenol in reducing the resident's temperature after administration. -- 4. References Obtained Via Internet (1) According to Medline Plus (a service of the U.S. National Library of Medicine / National Institutes of Health ), in an article titled ""Fever"": ""Fever is the temporary increase in the body's temperature in response to some disease or illness. ""... An adult probably has a fever when the temperature is above 99 - 99.5 ?F (37.2 - 37.5 ?C), depending on the time of day. ""... Call your doctor right away if you are an adult and you: - Have a fever over 105 ?F (40.5 ?C), unless it comes down readily with treatment and you are comfortable - Have a fever that stays at or keeps rising above 103 ?F - Have a fever for longer than 48 - 72 hours - Have had fevers come and go for up to a week or more, even if they are not very high - Have a serious medical illness, such as a heart problem, [MEDICAL CONDITION] cell [MEDICAL CONDITION], diabetes, [DIAGNOSES REDACTED], [MEDICAL CONDITION], or other chronic lung problems ... - Have trouble with your immune system (chronic steroid therapy, after a bone marrow or organ transplant, had spleen removed, HIV-positive, were being treated for [REDACTED]. (URL: http://www.nlm.nih.gov/medlineplus/ency/article/ 0.htm) -- (2) According to the Mayo Clinic, in an article titled ""Fever: First aid"": ""Fever is a sign of a variety of medical conditions, including infection. ""... Under the arm (axillary) ""Although it's not the most accurate way to take a temperature, you can also use an oral thermometer for an armpit reading: - Place the thermometer under your arm with your arm down. - Hold your arms across your chest. - Wait five minutes or as recommended by your thermometer's manufacturer. - Remove the thermometer and read the temperature. ""... An axillary reading is generally 1 degree Fahrenheit (about 0.5 degree Celsius) lower than an oral reading. ..."" (URL: ) -- (3) According to Drugs.com, in an article titled ""How To Take An Axillary Temperature"": ""What is it? ""An axillary (AK-sih-lar-e) temperature (TEM-per-ah-chur) is when your armpit (axilla) is used to check your temperature. A temperature measures body heat. A thermometer (there-MOM-uh-ter) is used to take the temperature in your armpit. An axillary temperature is lower than one taken in your mouth, rectum, or your ear. This is because the thermometer is not inside your body such as under your tongue. ""Why do I need to check an axillary temperature? ""An axillary temperature may be done to check for a fever. 'Fever' is a word used for a temperature that is higher than normal for the body. A fever may be a sign of illness, infection or other conditions. A normal axillary temperature is between 96.6? (35.9? C) and 98? F (36.7? C). The normal axillary temperature is usually a degree lower than the oral (by mouth) temperature. The axillary temperature may be as much as two degrees lower than the rectal temperature. Body temperature changes slightly through the day and night, and may change based on your activity. ... ""How do I use a digital thermometer? ""Wait at least 15 minutes after bathing or exercising before taking your axillary temperature. - Take the thermometer out of its holder. - Put the tip into a new throw-away plastic cover. If you do not have a cover, clean the pointed end (probe) with soap and warm water or rubbing alcohol. Rinse it with cool water. - Put the end with the covered tip securely in your armpit. Hold your arm down tightly at your side. - Keep the thermometer in your armpit until the digital thermometer beeps. - Remove the thermometer when numbers show up in the 'window'. - Read the numbers in the window. These numbers are your temperature. Add at least 1 degree to the temperature showing in the window. ..."" (URL: ) -- 5. Review of the facility's policy titled ""3.5 Vital Signs"" (revision date 10/01/10) revealed it was silent to how staff was to take a resident's temperature (e.g., route; device to be used; etc.). Review of the facility's document titled ""Clinical Competency Validation - Skill: Measuring Temperature, Pulse, and Respiration"" (revision date of 10/2009) revealed the steps to be taken by staff to measure and record a resident oral temperature. This document did not address how to measure a resident's axillary temperature. There was no policy or procedure available to address the difference between an axillary temperature reading and an oral temperature reading, such as whether to add 1 degree F when reading an axillary temperature or when an axillary temperature was elevated enough to require treatment with medication. -- 6. A review of the resident's care plan revealed the following: (a) A problem statement related to UTIs stated: ""(Resident #28) is at risk for complications of current UTI."" (This problem statement had a ""Date Initiated"" of 11/05/10, was ""Created on"" 11/11/10, and was revised on 11/17/10.) The goal associated with this problem statement was: ""Infection will be resolved within 14 days."" (This goal had a ""Date Initiated"" of 11/17/10, was ""Created on"" 11/11/10, was revised on 11/17/10, and had a ""Target Date"" of 12/01/10.) The interventions developed to achieve this goal were: - ""Monitor vital signs and report to physician as indicated."" (This intervention had a ""Date Initiated"" of 11/05/10, was ""Created on"" 11/11/10, and was revised on 11/17/10.) - ""Administer [MEDICATION NAME] as ordered."" (This intervention had a ""Date Initiated"" of 11/17/10, was ""Created on"" 11/11/10, and was revised on 11/17/10.) There was no mention anywhere in this 13-page care plan of the need to measure Resident #28's temperature via the axilla due to an inability to obtain a temperature reading via another route (e.g., oral, rectal, tympanic). Given that the resident's standing physician orders [REDACTED]. .",2014-04-01
11389,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2010-12-21,278,D,,,NKSJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of resident assessment data and physician orders, the facility failed, for one (1) of five (5) sampled residents, to ensure each resident assessment accurately reflected each resident's health status and condition. Resident #28's primary source of nutrition was received via a gastrostomy tube, but his most recent abbreviated quarterly assessment did not identify the presence of this feeding tube. Facility census: 68. Findings include: a) Resident #28 Record review, on 12/20/10 and 12/21/10, included a review of the resident's assessments and physician orders. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. In Section G, the assessor noted Resident #28 was totally dependent on one (1) staff member for eating. In Section K, the assessor noted he did NOT receive any nutrition through tube feeding. Review of the physician's orders [REDACTED]. - ""Peg tube: Magna ports 20 Fr. 10cc - FYI - Change when dysfunctional. May use 18 fr 10cc or 20 fr 10cc."" This order was originally given on 07/29/09 - ""[MEDICATION NAME] 1.5 at 85 cc (sic) hour for 20 hour cycle with 4 hours down time (sic) off at 6am (sic) on at 10 am (sic) continue with h2o (sic) flushes of 275cc (sic) every 4 hours for additional 1650ml (sic) a day. Hold if residual (sic) 100ml or over."" This order was originally given on 05/18/09. Review of the resident's most recent comprehensive assessment (MDS 2.0) with an ARD of 01/28/10 revealed, in Section K, the assessor did note the presence of a feeding tube, which was used to provide 76-100% of the resident's total daily calories and 2001 or more cc of fluid intake daily. .",2014-04-01
11390,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2010-12-29,329,D,,,CYQN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for one (1) of five (5) residents reviewed, to assure the resident's drug regimen was free of unnecessary drugs. A resident receiving a medication that had the ability to affect her level of consciousness, and which was ordered to treat the symptom of anxiety, was awakened by the nurse by having her face bathed with a cold cloth in order to receive an additional dose of that same medication. Resident identifier: #65. Facility census: 61. Findings include: a) Resident #65 When reviewed on 12/28/10, the closed medical record of Resident #65 divulged the resident had been admitted to the facility in February 2001 and was 80-years old at that time. When transferred to the hospital from the facility on 12/11/10, the resident's weight was noted to be 70 pounds. The resident was noted to have [DIAGNOSES REDACTED]. The resident's record further revealed she suffered with severe breathing problems and frequent episodes of anxiety, possibly associated with the inability to breathe without difficulty. The resident had been receiving the medication Klonopin for anxiety, in varying dosages since the time of admission to the facility. On 12/10/10, a physician's orders [REDACTED]. According to the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to http://www.fda.gov/downloads/Drugs/DrugSafety, the patient medication guide for the medication Klonopin indicated the most common side of the medication is drowsiness. Facility nurse's notes, on 12/11/10 at 10:50:57 a.m., stated, ""Klonopin 0.5mg given this am (morning) and resident very hard to awaken. Cold wash cloth applied to forehead and to resident's face. Resident aroused long enough to give meds. Also was unable to feed resident breakfast or to give am (morning) snack..."" The resident was not exhibiting the symptom of anxiety for which it was ordered, and she was actually experiencing a decreased level of consciousness prior to the administration of the dose (as stated in the 12/11/10 nurse's note). This documented statement would indicate the evening dose of the medication was unnecessary at that time. On 12/28/10 at approximately 4:00 p.m., the facility's director of nurses (DON), when questioned about this statement of the need to awaken a resident to administer an anti-anxiety medication, could provide no reason for a sleeping resident to be awakened to receive a medication prescribed to treat anxiety.",2014-04-01
11391,NELLA'S INC.,51A010,399 FERGUSON ROAD,ELKINS,WV,26241,2010-03-17,225,D,,,N9NH11,"**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 immediate report and/or thoroughly investigate allegations of abuse and/or neglect to the appropriate State agencies. This affected two (2) of three (3) sampled residents whose closed records were reviewed. Resident identifiers: #94 and #96. Facility census: 92. Findings include: a) The facility was entered at 1:00 p.m. on 03/15/10. At 1:15 p.m., a request was made of the social worker for records including all incident / accident reports, internal complaints, and allegations of abuse / neglect reported and investigated by the facility from 01/01/10 to the present. Within the hour, the incident / accident reports were submitted to this surveyor, but the social worker stated there had been no complaints or allegations received by the facility since 01/01/10. b) Resident #94 Review of Resident #94's closed medical record revealed a [AGE] year old male who was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Documentation reflected he refused to communicate most of the time and isolated himself from others. This behavior was not new and was related by family in his admission history. He had been determined by physician to lack capacity, and a family member was appointed to serve as his health care surrogate (HCS), although he was alert, could make his needs known, and understood what was said to him. He was discharged on [DATE], because of aggressive behaviors (both physical and verbal), after the nursing home stated they were unable to provide the care he needs. In an interview with the resident's HCS at 10:00 a.m. on 03/17/10, she stated she was relieved that he was no longer at the facility, because none of her complaints was ever addressed. She stated that, after his readmission from the hospital in January 2010, she was notified he was stockpiling razors in his room. She complained to the nursing home that, because of his behaviors, she had been told not to give him anything that could be used as a weapon. Since she was not supplying him with the razors, someone in the facility must have been giving them to him. She was told the facility would investigate, but she heard nothing else regarding this concern until the social worker related during an appeal hearing that the hoarding was a reason for his discharge. The HCS also reported having told the social worker, on a visit in the recent past, that Resident #94 had asked staff for a blanket as he was cold, but he was told he could not have one. She was told the facility would address this, but she never heard anything more on the matter. Prior to his discharge, the HCS visited him on 03/07/10 and found a wooden gate had been put across his doorway with a bolt lock on the outside. She stated that she immediately complained to the nurse, as she considered this to be resident abuse (involuntary seclusion). She said she took a picture of it with her phone and demanded it be removed. Again, she received no follow-up from the facility regarding her complaint, although she left the gate unlocked when she left the building. A review of incident / accident reports revealed none involving this resident. As noted above, there were no recorded complaints or allegations of abuse / neglect received by the facility during the last three (3) months. During an interview with the social worker and the director of nursing (DON) at 10:45 a.m. on 03/17/10, they stated they had never received a complaint or an allegation of abuse / neglect involving this resident. When asked about the specific incidents listed above, they knew about all of them, but they did not consider any of them to be allegations or complaints. They denied the HCS was upset about the gate and stated they thought she took a picture of it because she liked it. c) Resident #96 1. Review of Resident #96's closed record revealed this [AGE] year old female was initially admitted to the facility on [DATE]. According to her discharge tracking record, she was discharged from the facility on 02/18/10. According to the most recent quarterly assessment completed prior to her discharge, with an assessment reference date of 02/09/10, she was alert and oriented, and the assessor coded her as ""modified independence"" with cognitive skills for daily decision-making. 2. An interview conducted with Resident #96's daughter and medical power of attorney representative (MPOA), at 11:45 a.m. on 03/15/10, revealed she brought Resident #96 from the facility for a home visit on 02/13/10 and, because of concerns about her care and with the agreement of her mother (who has capacity), informed the nursing home the resident would not be returning. She reported having complained numerous times to the facility about care issues with no satisfactory responses or action being taken. The daughter stated she had complained to both the social worker and the DON about finding her mother dirty and unwashed when she visited on several occasions, and she reported she was told each time that it would be checked into, but she never received any follow-up on these concerns. The daughter also reported she had complained to the nursing staff, on 02/11/10, about large amounts of mucus coming from the resident's [MEDICAL CONDITION], because the resident had been treated for [REDACTED]. According to the daughter, she never received a response to this concern. 3. During an interview with the social worker at 1:00 p.m. on 03/16/10, she stated Resident #96's daughter had never placed a complaint of any kind with the facility. The social worker and the DON, when interviewed at 3:00 p.m. on 03/16/10, stated they had not been notified of any concern regarding large amounts of mucus coming from the resident's [MEDICAL CONDITION]. They again denied having ever received complaints or allegations of neglect involving this resident. d) The faciltiy failed to acknowledge that complaints filed on behalf of Residents #94 and #96 contained allegations of abuse and/or neglect, failed to immediately report these allegations to State agencies as required, and failed to thoroughly investigate these allegations. .",2014-04-01
11392,NELLA'S INC.,51A010,399 FERGUSON ROAD,ELKINS,WV,26241,2010-03-17,165,D,,,N9NH11,"**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 support each resident's right to voice grievances and failed, after receiving a complaint or grievance, to actively seek a resolution and keep the resident or his or her representative appropriately apprised of the facility's progress toward resolution. This affected three (3) of three (3) sampled residents whose closed records were reviewed. Resident identifiers: #94, #95, and #96. Facility census: 92. Findings include: a) The facility was entered at 1:00 p.m. on 03/15/10. At 1:15 p.m., a request was made of the social worker for records including all incident / accident reports, internal complaints, and allegations of abuse / neglect reported and investigated by the facility from 01/01/10 to the present. Within the hour, the incident / accident reports were submitted to this surveyor, but the social worker stated there had been no complaints or allegations received by the facility since 01/01/10. A review of the facility's complaint policy, provided by the social worker on 03/16/10, revealed the following: ""ALL COMPLAINTS RECEIVED BY THE FACILITY MUST BE DOCUMENTED IN THE COMPLAINT LOG, KEPT AT THE CHART DESK ON THE A-SIDE."" ""ALL COMPLAINTS AND SOLUTIONS SHOULD BE MAINTAINED IN A FILE FOR FUTURE REFERENCES, AFTER A COPY HAS BEEN SUBMITTED TO THE ADMINISTRATOR."" b) Resident #94 Review of Resident #94's closed medical record revealed a [AGE] year old male who was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Documentation reflected he refused to communicate most of the time and isolated himself from others. This behavior was not new and was related by family in his admission history. He had been determined by physician to lack capacity, and a family member was appointed to serve as his health care surrogate (HCS), although he was alert, could make his needs known, and understood what was said to him. He was discharged on [DATE], because of aggressive behaviors (both physical and verbal), after the nursing home stated they were unable to provide the care he needs. In an interview with the resident's HCS at 10:00 a.m. on 03/17/10, she stated she was relieved that he was no longer at the facility, because none of her complaints was ever addressed. She stated that, after his readmission from the hospital in January 2010, she was notified he was stockpiling razors in his room. She complained to the nursing home that, because of his behaviors, she had been told not to give him anything that could be used as a weapon. Since she was not supplying him with the razors, someone in the facility must have been giving them to him. She was told the facility would investigate, but she heard nothing else regarding this concern until the social worker related during an appeal hearing that the hoarding was a reason for his discharge. The HCS also reported having told the social worker, on a visit in the recent past, that Resident #94 had asked staff for a blanket as he was cold, but he was told he could not have one. She was told the facility would address this, but she never heard anything more on the matter. Prior to his discharge, the HCS visited him on 03/07/10 and found a wooden gate had been put across his doorway with a bolt lock on the outside. She stated that she immediately complained to the nurse, as she considered this to be resident abuse (involuntary seclusion). She said she took a picture of it with her phone and demanded it be removed. Again, she received no follow-up from the facility regarding her complaint, although she left the gate unlocked when she left the building. A review of incident / accident reports revealed none involving this resident. As noted above, there were no recorded complaints or allegations of abuse / neglect received by the facility during the last three (3) months. During an interview with the social worker and the director of nursing (DON) at 10:45 a.m. on 03/17/10, they stated they had never received a complaint or an allegation of abuse / neglect involving this resident. When asked about the specific incidents listed above, they knew about all of them, but they did not consider any of them to be allegations or complaints. They denied the HCS was upset about the gate and stated they thought she took a picture of it because she liked it. c) Resident #95 Review of Resident #95's closed record revealed an [AGE] year old male who was admitted to the facility on [DATE], and who was discharged to another nursing home on 03/01/10 at the request of his HCS, who was the DHHR case worker. Further review of the record revealed a nursing note, for the morning of 02/10/10, recording that the resident's daughter contacted the social worker to complain about not having been informed of the resident having been sent to the hospital emergency roiagnom on the previous day. The family learned about the transfer on 02/10/10 from the DHHR case worker who, according to the notes, had instructed the facility's social worker to keep the resident's family informed when he was sent to the hospital, even though they were not the resident's legal decision makers. Although there was documentation to reflect numerous phone calls made to DHHR regarding the resident's status, there was no evidence the family was informed when changes occurred in the resident's condition or treatment. At 5:00 p.m. on 02/10/10, the DON recorded in the resident's record that she had received a call from the WV State Police informing her the resident's family had complained that the resident had been sent to the hospital but the facility would not tell them where. During an interview with the social worker and the DON at 1:30 p.m. on 03/16/10, they stated they did not consider the above incident a complaint, because the family was not the resident's responsible person and had no right to complain. They stated that the only reason for the voluminous documentation in the chart was for ""legal reasons"". d) Resident #96 1. Review of Resident #96's closed record revealed this [AGE] year old female was initially admitted to the facility on [DATE]. According to her discharge tracking record, she was discharged from the facility on 02/18/10. According to the most recent quarterly assessment completed prior to her discharge, with an assessment reference date of 02/09/10, she was alert and oriented, and the assessor coded her as ""modified independence"" with cognitive skills for daily decision-making. 2. An interview conducted with Resident #96's daughter and medical power of attorney representative (MPOA), at 11:45 a.m. on 03/15/10, revealed she brought Resident #96 from the facility for a home visit on 02/13/10 and, because of concerns about her care and with the agreement of her mother (who has capacity), informed the nursing home the resident would not be returning. She reported having complained numerous times to the facility about care issues with no satisfactory responses or action being taken. The daughter reported Resident #96 fell at the facility on 01/29/10, sustaining numerous bruises on her face, legs, hip, abdomen, and back and a laceration on her right calf; she was taken to the emergency room and returned to the facility. The daughter questioned facility staff about how the fall happened and was told it happened in the dining room, but she was never given any additional information. It was at this point the family member started making arrangements to care for her mother at home. The daughter stated she had complained to both the social worker and the DON about finding her mother dirty and unwashed when she visited on several occasions, and she reported she was told each time that it would be checked into, but she never received any follow-up on these concerns. The daughter reported that a motorized scooter was purchased for the resident's use, and the family was told the resident could use it after being taught how to safely do so by physical therapy. The therapist notified the family by phone the resident could not use the scooter, because he had been notified that she had run it into a wall. The daughter also reported she had complained to the nursing staff, on 02/11/10, about large amounts of mucus coming from the resident's [MEDICAL CONDITION], because the resident had been treated for [REDACTED]. According to the daughter, she never received a response to this concern. 3. Record review found an incident / accident report, dated 01/29/10, which noted the resident had fallen while using her walker; documentation on the report confirmed injuries were sustained as a result of this fall. Documentation on the report also indicated the family was notified of the fall, but there was no mention on the report of the family having questioned the circumstances of the fall. Review of Resident #96's closed record found the only documentation about the scooter was a physical therapy note on 02/10/10, which recorded the resident was being evaluated for a scooter. There was no incident / accident report or other documentation about the resident running the scooter into a wall, and no one at the facility (including the physical therapist), when questioned by this surveyor, could remembered any incident involving the resident having done this. 4. During an interview with the social worker at 1:00 p.m. on 03/16/10, she stated Resident #96's daughter had never placed a complaint of any kind with the facility. The social worker and the DON, when interviewed at 3:00 p.m. on 03/16/10, stated they had not been notified of any concern regarding large amounts of mucus coming from the resident's [MEDICAL CONDITION]. They also denied that anyone had ever complained about the resident not being allowed to use the scooter. They again denied having ever received complaints or allegations of neglect involving this resident. e) The facility failed to support each resident's right to voice grievances, by failing to register and respond to all complaints filed on behalf of Residents #94, #95, and #96 by their family members or legal representatives. .",2014-04-01
11393,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2010-12-07,323,G,,,EBZE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of facility incident / accident reports, observation, staff interview, and resident interview, the facility failed, for three (3) of five (5) residents reviewed, to provide an environment that is free from accident hazards over which the facility has control and failed to provide adequate supervision and/or assistive devices to prevent avoidable accidents. Three (3) residents, who were known to wander, sustained injuries during this unsupervised wandering, and the facility failed to review / revise their care plans and implement new interventions to promote their safety when the existing care plan interventions were ineffective in preventing further injury. Residents #19, #20, and #36 wandered unsupervised throughout the facility. Although incident / accident reports disclosed these residents had sustained numerous injuries while wandering, the facility failed to evaluate and analyze hazards and failed to attempt to revise or implement additional measures that would prevent injury during the wandering episodes. Resident #19 had repeated falls, was slapped and shaken by other residents, and placed in her mouth items she had removed from the trash. Resident #20 had repeated falls, sustained a head laceration that required closure with staples as a result of one (1) fall and a dislocated shoulder following another fall. Resident #36 was known to have aggressive behaviors and to wander unsupervised about the facility; no attempt was made to manage these behaviors, which resulted in an altercation with another resident ending with a head laceration that required closure with sutures. Facility census: 44. Findings include: a) Resident #19 1. The medical record of Resident #19, when reviewed on 12/06/10, revealed the resident had been admitted to the facility on [DATE], with medical [DIAGNOSES REDACTED]. This [AGE] year old female resident spoke very little English and was hard of hearing. At the time of admission, her physician determined she lacked the capacity to understand and make informed health care decisions. - 2. Review, on 12/06/10, of the facility's incident / accident reports for the months of October and November 2010 disclosed the following: - On 11/14/10 at 11:30 p.m., staff found Resident #19 on the floor in another resident's room, when they responded to Resident #19's yelling. On 11/17/10, the resident was noted to have ""bruising each side of her nose"" which was attributed to the 11/14/10 incident. - On 11/23/10 at 9:15 p.m., a report stated the resident was ""slapped across the L (left) side of her face when resident (#19) tried to climb into bed with resident # (another resident)."" - On 11/25/10 at 8:30 p.m., a report stated, ""Resident at med cart taking something out of trash and appeared to have put dirty spoon in mouth from the trash."" - On 11/27/10 at 5:00 p.m., another report stated, ""CNA (certified nursing assistant) called my attention to a 3 cm round bruise on resident's L (left) hip. No pain noted."" No explanation was offered as to the cause of this injury. - 3. Review of the resident's nursing notes revealed the following: - On 07/09/10 at 11:00 p.m., ""CNA walking past room (#) she saw resident # (another resident) shove res. (Resident #19) out the door. Res. (#19) was holding a packet of tarter (sic) sauce and res. # (other resident) smashed res's (#19's) hand into her face causing sauce packet to hit her face. ..."" - On 07/29/10 at 6:00 a.m., ""Wandering in and out of other resident's rooms and undressing them. Difficult to re-direct."" - On 09/11/10 at 10:00 p.m. (recorded in a late entry dated 09/12/10 at 5:30 p.m.), ""Resident was going into other resident's rooms and resident # (another resident) was seen by CNA (name) to have ahold (sic) of both of resident's arms and was shaking her. ..."" Numerous other entries by facility nurses during the time period of 07/09/10 to present (12/06/10) stated Resident #19 was up wandering throughout the building in and out of other residents' rooms. - 4. Resident #19's room was observed on numerous occasions during this investigation, and a mattress pressure alarm was noted to be on the bed which was in the low position. No other special findings were observed. - 5. Resident #19's care plan, when reviewed on 12/06/10, revealed that, at the time of admission to the facility on [DATE], staff had identified the following problem: ""Potential for fall r/t (related to) wandering. Ambulates ad lib into other residents (sic) rooms."" The goal associated with this problem statement was for this resident to ""wander safely and have no injuries r/t falls through review date."" Approaches to assist the resident in attaining this goal included providing safe footwear, being sure call light was within reach, anticipating and meeting the resident's needs, ensuring a safe environment with floors free of spills / clutter, placing the bed in low position and personal items within reach providing activities to minimize the potential for falls, and applying a WanderGard bracelet to alert staff of the resident's attempts to exit facility. A comparison of the resident's current care plan (last revised on 11/11/10) with the care plan developed after her admission found that, even though she had experienced numerous falls, altercations with other residents, searching garbage, the problem statement, goal, and approaches remained the same, with the exception of the addition, on 06/23/10, of Posey hipsters (to reduce the risk of injury during falls) and an alarming mattress pad to bed (to alert staff of her desire to move). No additional interventions had been added to promote the resident's safety when wandering, even though she continued to sustain injuries and be abused by other residents. - 6. The director of nursing (DON), when interviewed on 12/06/10 regarding what steps the facility had taken to promote the safety of wandering residents, stated they used some of the barrier-type stop signs (banners that were attached to the both sides of the door frame of a corridor door to deter wanderers from entering a resident's room) and tried to re-direct the residents. She stated she was unsure what other steps could be taken, noting that the residents had the right to wander. - 7. Resident #24, when asked if he was bothered by wandering residents during an interviewed 12/06/10 at 12:15 p.m., stated that yes he was and that Resident #20 had wandered into his room the previous night, taken his soft drink, and dumped it into the sink. When asked what he did in response, he stated that he ""took ahold of him (Resident #20)"" then a nurse came in and told him he couldn't do that. When asked if a barrier-type stop sign had ever been offered to him to deter wanderers from entering his room, Resident #24 stated, ""No."" - 8. Following the interview with Resident #24, the facility was toured and observation found only two (2) barrier-type stop signs in use on two (2) resident rooms, but the devices were not attached in a manner that would deter a wanderer; in both cases, the banners were hanging on one (1) side of the doorway instead of being secured across the doorways as intended. On the second day of the investigation (12/07/10), observation found three (3) such barriers in place. The third barrier was noted to be across the entrance to Resident #24's room. When interviewed again on 12/07/10 at 11:00 a.m., Resident #24 stated he asked staff for the barrier after speaking with this surveyor the previous day. -- b) Resident #20 1. The medical record of Resident #20, when reviewed on 12/07/10, disclosed this [AGE] year old male had been admitted to the facility on [DATE] following hospitalization at an area hospital after the family could no longer care for him at home. His medical [DIAGNOSES REDACTED]. At the time of admission, the resident had been determined to lack the capacity to understand and make his own medical decisions. The DON, when interviewed on 12/06/10 at 11:45 a.m., stated this resident was one (1) of several who wandered about the facility and into other resident rooms. - 2. Review of the resident's nursing notes revealed the following: - On 09/30/10 at 10:30 p.m., the resident fell in the restroom and was found by a nursing assistant when the bed alarm sounded. He sustained two (2) bumps on his head. - On 10/07/10 at 12:30 a.m., the resident had taken the body alarm off of his shirt when he got up and was found by nursing assistants on his roommate's fall mat. - On 10/07/10 at 9:30 p.m., the resident was found on his resident's fall mat with his ""head gashed open"". He was sent to the emergency room (ER) and received four (4) staples to a laceration on the back of his head. - On 10/10/10 at 3:45 p.m., the resident was found sitting on the floor in another resident ' s room with no injuries noted. - On 10/11/10 at 5:00 a.m., the resident was found "" lying on floor with roll table over him."" Notes stated, ""Body alarm was removed ... also lying by fall mat of resident (roommate) which may have caused fall."" - On 10/11/10 at 9:30 a.m., the resident was ""found lying on fall mat in his room (sic) assisted back to bed."" - On 10/13/10 at 12:30 a.m., the resident was walking up to nurse's station and fell over his own feet. ""fell on R knee and R elbow."" - On 10/14/10 at 10:15 a.m., ""Resident exited facility through Activity Room Door. Brought back in without difficulty."" - On 10/19/10, ""Resident sitting in G/C (geri-chair) and slid out onto floor and the leather part of the seat slid out with resident. No injuries, G/C removed from the floor."" - On 10/20/10 at 1:15 a.m., the resident was found lying on fall mat in another resident's room. - On 10/24/10 at 2:15 p.m., the resident exited the facility through the activities lounge and was brought back in by a nursing assistant. - On 10/27/10 at 1:30 a.m., the resident slid out of chair at nurse's station and hit his forehead on wall. - On 10/30/10 at 8:10 p.m., ""Resident was found lying on DR (dining room) floor, left arm on furnace register, urine on floor."" - On 10/31/10 at 6:45 p.m., the resident was witnessed tripping over another resident's wheelchair while exiting the dining room in front lobby; the resident's right elbow struck the ""grate"" beside reception office, incurring a skin tear. - On 11/03/10 at 5:55 p.m., an activity assistant found the resident sitting by his bed on the floor. ""Resident still had his support hose on."" - On 11/15/10 at 10:05 p.m., ""Heard resident yelling, found resident laying on the floor in resident's room."" The resident was assisted back to bed with no injuries noted. - On 11/21/10 at 12:15 a.m., the resident was found sleeping on floor mat in another resident ' s room. - On 11/30/10 (no time), a nurse aide walked into the resident's room and found the resident lying in the floor. ""Resident holding his head (sic) no bruise or injury to head. Resident picked up off floor and put back to bed."" - On 12/01/10 at 12 p.m., the resident was showing signs of pain to the left shoulder. The physician ordered an x-ray to the shoulder, which revealed a slight dislocation of the left shoulder. At 7:30 p.m., the physician ordered the resident be sent to ER. At 8:15 p.m., before emergency services personnel (EMS) could arrive for transfer, the resident fell again. Notes stated, ""Not sure if (fall was) from bed or chair."" The resident sustained [REDACTED]. EMS arrived at that time to transport to ER. The resident returned on 12/01/10 at 10:45 p.m. with no new orders. - On 12/03/10, ""Resident's bed alarm ringing and was on the floor skin tear to R (right) knee."" - 3. When interviewed at 2:20 p.m. on 12/07/10 about what interventions the facility had considered / implemented to protect Resident #20 from falls, the DON stated the resident had a body alarm on when in bed, a bed alarm, and a low bed. Observation, at 2:34 p.m. on 12/07/10, found Resident #20 lying on his bed. There was no body alarm present in the room, and the bed alarm was disconnected. This observation was confirmed by the DON, who stated, ""It can't work if it's not connected."" - 4. Regarding the fall that occurred at 5:00 a.m. on 10/11/10, which staff noted may have been caused by the presence of a floor mat, there was no evidence that environmental changes (such as a room change) were implemented at that time. On 10/27/10, a nursing note stated Resident #20's family requested a private room, and the resident was moved. When interviewed related to this finding on 12/07/10 at 2:20 p.m., the DON stated no private room was available at the time the resident was thought to have fallen on his roommate's fall mat. She confirmed that Resident #20 could have been moved to a room with another resident who did not need a fall mat, although she stated Resident #20 needed a fall mat himself. The resident had no fall mat at any time during this investigation, and there was no mat in his room. - 5. A nursing assistant who frequently cared for Resident #20 (Employee #74) was asked what measures were taken to protect this resident from falls. She responded that he had a bed alarm and she was not sure if he used a fall mat. - 6. Review of Resident #20's care plan revealed that, at the time of his admission to the facility on [DATE], staff had identified he was at risk for falls related to psychotropic drug use and he had the potential for ""adverse (illegible) behaviors due to new admission to nursing home such as wandering, resisting care."" Goals for both of these problems were for the resident to wander safely, and approaches established at that time included the use of a WanderGard bracelet, low bed, and body alarm when in bed and keeping the call light in his reach. The resident's most recently updated care plan remained identical with the above problems, goals, and approaches, with the exception of an added approach to use bedroom slippers when ambulating and a physical therapy evaluation (which was ordered by the physician on 12/07/10). - 7. The DON could provide no evidence that other interventions / devices had been considered and/or implemented for this resident, who was noted on incident / accident reports to have fallen twenty (20) times since his admission three (3) months prior in September 2010. -- c) Resident #36 1. When interviewed on 12/06/10 at 12:45 p.m., the DON identified Resident #36 as one (1) of several residents who wandered about the facility. The DON further described an altercation that occurred between Resident #36 and another resident which resulted in a head laceration to Resident #36 that required closure with sutures. Review of Resident #36's medical record, on 12/07/10, disclosed this [AGE] year old male resident was admitted to this facility on 05/15/09 with [DIAGNOSES REDACTED]. At the time of admission, the resident had been determined to lack the capacity to understand and make his own medical decisions. - 2. The resident's admission plan of care contained the following problem statement: ""High risk for falls r/t (related to) h/o (history of) falls, use of antianxiety and antidepressant meds and wandering behavior."" The goal related to this problem statement was: ""Resident to remain safe, free from injury."" Approaches to assist the resident in attaining this goal included: ""Provide safe environment, bed in low position, side rails as ordered. Encourage appropriate footwear. Redirect / re-orient as needed."" The resident's current care plan (last revised on 11/23/10) contained the same problems, goals, and approaches as those contained in the care plan developed on admission in 2009. - 3. Review of the resident's nursing notes disclosed the following: - On 08/27/10 at 7:15 p.m., a note described a confrontation between Resident #36 and another resident when Resident #36 entered his room and told him to leave. Resident #36 hit the other resident on the chin with his fist; staff re-directed Resident #36 after the incident. - On 09/28/10 at 10:30 p.m., a note stated Resident #36 was sleeping in another resident's bed. When staff attempted to take Resident #36 to his own bed, he became combative, hitting and kicking staff. - On 09/29/10 at 5:45 p.m., in the main dining room, Resident #36 became agitated for ""no known reason"" and was noted to have said, ""I'm gonna give him one."" The resident was removed from the dining area. - On 10/02/10, the resident was attempting to push residents in their wheelchairs and was redirected. - On 10/31/10 at 10:40 p.m., the resident was noted to have grabbed the roll walker of another resident when he lost his balance and fell . - On 11/03/10, Resident #36 ""punched CNA in eye (sic) knocking off CNA's glasses (sic) causing red area to eye."" - On 11/11/10 at 9:45 p.m., Resident #36 entered the room of another resident and was hit over the head by the other resident with his cane. Resident #36 sustained a laceration and was sent to the ER. The resident returned with six (6) staples to the top of his head and steri-strips to his right eye. - On 12/01/10, the resident was noted to kick a nursing assistant in the eye causing a cut to her eyelid. - 4. Resident #36's room was observed on numerous occasions during this investigation, and a mattress pressure alarm was noted to be on the bed which was in the low position. No other special findings were observed. - 5. The DON, when asked what interventions the facility had implemented to assure Resident #36 would not harm himself or others (especially following the altercation with the other resident which resulted in a head injury to this resident), stated that the other resident was no longer at the facility and that this resident had been transferred to another room. Although the facility was fully aware of the resident's aggressive / combative behaviors, there had been no attempt to implement interventions in an effort to assure the safety of this resident and others.",2014-04-01
11394,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2010-12-07,280,D,,,EBZE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of facility incident / accident reports, observation, staff interview, and resident interview, the facility failed, for three (3) of five (5) residents reviewed, to review / revise their care plans with new interventions to promote their safety when the existing care plan interventions were ineffective in preventing further injury. Resident identifiers: #19, #20, and #36. Facility census: 44. Findings include: a) Resident #19 1. The medical record of Resident #19, when reviewed on 12/06/10, revealed the resident had been admitted to the facility on [DATE], with medical [DIAGNOSES REDACTED]. This [AGE] year old female resident spoke very little English and was hard of hearing. At the time of admission, her physician determined she lacked the capacity to understand and make informed health care decisions. - 2. Review, on 12/06/10, of the facility's incident / accident reports for the months of October and November 2010 disclosed the following: - On 11/14/10 at 11:30 p.m., staff found Resident #19 on the floor in another resident's room, when they responded to Resident #19's yelling. On 11/17/10, the resident was noted to have ""bruising each side of her nose"" which was attributed to the 11/14/10 incident. - On 11/23/10 at 9:15 p.m., a report stated the resident was ""slapped across the L (left) side of her face when resident (#19) tried to climb into bed with resident # (another resident)."" - On 11/25/10 at 8:30 p.m., a report stated, ""Resident at med cart taking something out of trash and appeared to have put dirty spoon in mouth from the trash."" - On 11/27/10 at 5:00 p.m., another report stated, ""CNA (certified nursing assistant) called my attention to a 3 cm round bruise on resident's L (left) hip. No pain noted."" No explanation was offered as to the cause of this injury. - 3. Review of the resident's nursing notes revealed the following: - On 07/09/10 at 11:00 p.m., ""CNA walking past room (#) she saw resident # (another resident) shove res. (Resident #19) out the door. Res. (#19) was holding a packet of tarter (sic) sauce and res. # (other resident) smashed res's (#19's) hand into her face causing sauce packet to hit her face. ..."" - On 07/29/10 at 6:00 a.m., ""Wandering in and out of other resident's rooms and undressing them. Difficult to re-direct."" - On 09/11/10 at 10:00 p.m. (recorded in a late entry dated 09/12/10 at 5:30 p.m.), ""Resident was going into other resident's rooms and resident # (another resident) was seen by CNA (name) to have ahold (sic) of both of resident's arms and was shaking her. ..."" Numerous other entries by facility nurses during the time period of 07/09/10 to present (12/06/10) stated Resident #19 was up wandering throughout the building in and out of other residents' rooms. - 4. Resident #19's room was observed on numerous occasions during this investigation, and a mattress pressure alarm was noted to be on the bed which was in the low position. No other special findings were observed. - 5. Resident #19's care plan, when reviewed on 12/06/10, revealed that, at the time of admission to the facility on [DATE], staff had identified the following problem: ""Potential for fall r/t (related to) wandering. Ambulates ad lib into other residents (sic) rooms."" The goal associated with this problem statement was for this resident to ""wander safely and have no injuries r/t falls through review date."" Approaches to assist the resident in attaining this goal included providing safe footwear, being sure call light was within reach, anticipating and meeting the resident's needs, ensuring a safe environment with floors free of spills / clutter, placing the bed in low position and personal items within reach providing activities to minimize the potential for falls, and applying a WanderGard bracelet to alert staff of the resident's attempts to exit facility. A comparison of the resident's current care plan (last revised on 11/11/10) with the care plan developed after her admission found that, even though she had experienced numerous falls, altercations with other residents, searching garbage, the problem statement, goal, and approaches remained the same, with the exception of the addition, on 06/23/10, of Posey hipsters (to reduce the risk of injury during falls) and an alarming mattress pad to bed (to alert staff of her desire to move). No additional interventions had been added to promote the resident's safety when wandering, even though she continued to sustain injuries and be abused by other residents. - 6. The director of nursing (DON), when interviewed on 12/06/10 regarding what steps the facility had taken to promote the safety of wandering residents, stated they used some of the barrier-type stop signs (banners that were attached to the both sides of the door frame of a corridor door to deter wanderers from entering a resident's room) and tried to re-direct the residents. She stated she was unsure what other steps could be taken, noting that the residents had the right to wander. -- b) Resident #20 1. The medical record of Resident #20, when reviewed on 12/07/10, disclosed this [AGE] year old male had been admitted to the facility on [DATE] following hospitalization at an area hospital after the family could no longer care for him at home. His medical [DIAGNOSES REDACTED]. At the time of admission, the resident had been determined to lack the capacity to understand and make his own medical decisions. The DON, when interviewed on 12/06/10 at 11:45 a.m., stated this resident was one (1) of several who wandered about the facility and into other resident rooms. - 2. Review of the resident's nursing notes revealed the following: - On 09/30/10 at 10:30 p.m., the resident fell in the restroom and was found by a nursing assistant when the bed alarm sounded. He sustained two (2) bumps on his head. - On 10/07/10 at 12:30 a.m., the resident had taken the body alarm off of his shirt when he got up and was found by nursing assistants on his roommate's fall mat. - On 10/07/10 at 9:30 p.m., the resident was found on his resident's fall mat with his ""head gashed open"". He was sent to the emergency room (ER) and received four (4) staples to a laceration on the back of his head. - On 10/10/10 at 3:45 p.m., the resident was found sitting on the floor in another resident ' s room with no injuries noted. - On 10/11/10 at 5:00 a.m., the resident was found "" lying on floor with roll table over him."" Notes stated, ""Body alarm was removed ... also lying by fall mat of resident (roommate) which may have caused fall."" - On 10/11/10 at 9:30 a.m., the resident was ""found lying on fall mat in his room (sic) assisted back to bed."" - On 10/13/10 at 12:30 a.m., the resident was walking up to nurse's station and fell over his own feet. ""fell on R knee and R elbow."" - On 10/14/10 at 10:15 a.m., ""Resident exited facility through Activity Room Door. Brought back in without difficulty."" - On 10/19/10, ""Resident sitting in G/C (geri-chair) and slid out onto floor and the leather part of the seat slid out with resident. No injuries, G/C removed from the floor."" - On 10/20/10 at 1:15 a.m., the resident was found lying on fall mat in another resident's room. - On 10/24/10 at 2:15 p.m., the resident exited the facility through the activities lounge and was brought back in by a nursing assistant. - On 10/27/10 at 1:30 a.m., the resident slid out of chair at nurse's station and hit his forehead on wall. - On 10/30/10 at 8:10 p.m., ""Resident was found lying on DR (dining room) floor, left arm on furnace register, urine on floor."" - On 10/31/10 at 6:45 p.m., the resident was witnessed tripping over another resident's wheelchair while exiting the dining room in front lobby; the resident's right elbow struck the ""grate"" beside reception office, incurring a skin tear. - On 11/03/10 at 5:55 p.m., an activity assistant found the resident sitting by his bed on the floor. ""Resident still had his support hose on."" - On 11/15/10 at 10:05 p.m., ""Heard resident yelling, found resident laying on the floor in resident's room."" The resident was assisted back to bed with no injuries noted. - On 11/21/10 at 12:15 a.m., the resident was found sleeping on floor mat in another resident ' s room. - On 11/30/10 (no time), a nurse aide walked into the resident's room and found the resident lying in the floor. ""Resident holding his head (sic) no bruise or injury to head. Resident picked up off floor and put back to bed."" - On 12/01/10 at 12 p.m., the resident was showing signs of pain to the left shoulder. The physician ordered an x-ray to the shoulder, which revealed a slight dislocation of the left shoulder. At 7:30 p.m., the physician ordered the resident be sent to ER. At 8:15 p.m., before emergency services personnel (EMS) could arrive for transfer, the resident fell again. Notes stated, ""Not sure if (fall was) from bed or chair."" The resident sustained [REDACTED]. EMS arrived at that time to transport to ER. The resident returned on 12/01/10 at 10:45 p.m. with no new orders. - On 12/03/10, ""Resident's bed alarm ringing and was on the floor skin tear to R (right) knee."" - 3. When interviewed at 2:20 p.m. on 12/07/10 about what interventions the facility had considered / implemented to protect Resident #20 from falls, the DON stated the resident had a body alarm on when in bed, a bed alarm, and a low bed. - 4. Regarding the fall that occurred at 5:00 a.m. on 10/11/10, which staff noted may have been caused by the presence of a floor mat, there was no evidence that environmental changes (such as a room change) were implemented at that time. On 10/27/10, a nursing note stated Resident #20's family requested a private room, and the resident was moved. When interviewed related to this finding on 12/07/10 at 2:20 p.m., the DON stated no private room was available at the time the resident was thought to have fallen on his roommate's fall mat. She confirmed that Resident #20 could have been moved to a room with another resident who did not need a fall mat, although she stated Resident #20 needed a fall mat himself. The resident had no fall mat at any time during this investigation, and there was no mat in his room. - 5. A nursing assistant who frequently cared for Resident #20 (Employee #74) was asked what measures were taken to protect this resident from falls. She responded that he had a bed alarm and she was not sure if he used a fall mat. - 6. Review of Resident #20's care plan revealed that, at the time of his admission to the facility on [DATE], staff had identified he was at risk for falls related to [MEDICAL CONDITION] drug use and he had the potential for ""adverse (illegible) behaviors due to new admission to nursing home such as wandering, resisting care."" Goals for both of these problems were for the resident to wander safely, and approaches established at that time included the use of a WanderGard bracelet, low bed, and body alarm when in bed and keeping the call light in his reach. The resident's most recently updated care plan remained identical with the above problems, goals, and approaches, with the exception of an added approach to use bedroom slippers when ambulating and a physical therapy evaluation (which was ordered by the physician on 12/07/10). - 7. The DON could provide no evidence that other interventions / devices had been considered and/or implemented for this resident, who was noted on incident / accident reports to have fallen twenty (20) times since his admission three (3) months prior in September 2010. -- c) Resident #36 1. When interviewed on 12/06/10 at 12:45 p.m., the DON identified Resident #36 as one (1) of several residents who wandered about the facility. The DON further described an altercation that occurred between Resident #36 and another resident which resulted in a [MEDICAL CONDITION] to Resident #36 that required closure with sutures. Review of Resident #36's medical record, on 12/07/10, disclosed this [AGE] year old male resident was admitted to this facility on 05/15/09 with [DIAGNOSES REDACTED]. At the time of admission, the resident had been determined to lack the capacity to understand and make his own medical decisions. - 2. The resident's admission plan of care contained the following problem statement: ""High risk for falls r/t (related to) h/o (history of) falls, use of antianxiety and antidepressant meds and wandering behavior."" The goal related to this problem statement was: ""Resident to remain safe, free from injury."" Approaches to assist the resident in attaining this goal included: ""Provide safe environment, bed in low position, side rails as ordered. Encourage appropriate footwear. Redirect / re-orient as needed."" The resident's current care plan (last revised on 11/23/10) contained the same problems, goals, and approaches as those contained in the care plan developed on admission in 2009. - 3. Review of the resident's nursing notes disclosed the following: - On 08/27/10 at 7:15 p.m., a note described a confrontation between Resident #36 and another resident when Resident #36 entered his room and told him to leave. Resident #36 hit the other resident on the chin with his fist; staff re-directed Resident #36 after the incident. - On 09/28/10 at 10:30 p.m., a note stated Resident #36 was sleeping in another resident's bed. When staff attempted to take Resident #36 to his own bed, he became combative, hitting and kicking staff. - On 09/29/10 at 5:45 p.m., in the main dining room, Resident #36 became agitated for ""no known reason"" and was noted to have said, ""I'm gonna give him one."" The resident was removed from the dining area. - On 10/02/10, the resident was attempting to push residents in their wheelchairs and was redirected. - On 10/31/10 at 10:40 p.m., the resident was noted to have grabbed the roll walker of another resident when he lost his balance and fell . - On 11/03/10, Resident #36 ""punched CNA in eye (sic) knocking off CNA's glasses (sic) causing red area to eye."" - On 11/11/10 at 9:45 p.m., Resident #36 entered the room of another resident and was hit over the head by the other resident with his cane. Resident #36 sustained a laceration and was sent to the ER. The resident returned with six (6) staples to the top of his head and steri-strips to his right eye. - On 12/01/10, the resident was noted to kick a nursing assistant in the eye causing a cut to her eyelid. - 4. Resident #36's room was observed on numerous occasions during this investigation, and a mattress pressure alarm was noted to be on the bed which was in the low position. No other special findings were observed. - 5. The DON, when asked what interventions the facility had implemented to assure Resident #36 would not harm himself or others (especially following the altercation with the other resident which resulted in a head injury to this resident), stated that the other resident was no longer at the facility and that this resident had been transferred to another room. Although the facility was fully aware of the resident's aggressive / combative behaviors, there had been no attempt to implement interventions in an effort to assure the safety of this resident and others. .",2014-04-01
11395,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2010-11-03,281,D,,,3TTH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of facility incident / accident reports, staff interview, and review of the Criteria for Determining Scope of Practice for Licensed Nurses published by the State licensing boards for registered professional nurses and licensed practical nurses (LPNs), the facility failed to provide services that meet professional standards of quality, as evidenced by the facility allowing an unknown employee to obtain intravenous access through an improper access site. One (1) of thirteen (13) residents on the sample was affected. Resident identifier: #109. Facility census: 108. Findings include: a) Resident #109 Review of an incident / accident report dated 07/28/10 revealed an unknown employee had obtained intravenous access through Resident #109's port-a-cath without a physician's orders [REDACTED]. Review of the nurses note revealed no documentation of the incident and no clarification of the physician's orders. Review of the physician's orders [REDACTED]."" Another hand-written entry, with no date, stating access port-a-cath times three (3) weeks after the following order: ""[MEDICATION NAME] HCl 1 gram Intravenous (IV) - Q12H Everyday, 0900 2100: 1 gram Q12 [MEDICAL CONDITION]."" An interview with the director of nursing (DON - Employee #106), on 11/03/10 at 3:00 p.m., revealed the DON agreed that a port-a-cath should never be used as an intravenous access site without a physician's orders [REDACTED]. Review of the Criteria for Determining Scope of Practice for Licensed Nurses, revised in 2009, revealed a Scope of Practice Model for the Advanced Practice Nurse, Registered Nurse, and Licensed Practical Nurse. Review of the Practice Model for the Advanced Practice Nurse, Registered Nurse, and Licensed Practical Nurse revealed a guideline stating: ""Is there a written order from a licensed Physician, Physician's Assistant, or Advanced Practice Nurse or is there a signed written protocol? If No, report / defer to qualified individual."" Further review also revealed a guideline stating: ""Would a reasonable and prudent nurse perform the act? If No, report / defer to qualified individual."" .",2014-03-01
11396,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2010-11-03,309,D,,,3TTH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of facility incident / accident reports, and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, as evidenced by the facility allowed an employee to provide care to a resident without a physician's directive. One (1) of thirteen (13) residents on the sample was affected. Resident identifier: #109. Facility census: 108. Findings include: a) Resident #109 Review of an incident / accident report, dated 07/28/10, revealed a registered nurse (RN - Employee #111) went into resident's room to unhook intravenous access, and when she unhooked the intravenous access device, she realized that access had been obtained through a [MEDICAL TREATMENT] port-a-cath. Employee #111 stated she then unhooked the intravenous access device and flushed the [MEDICAL TREATMENT] port-a-cath. Review of the alleged abuse interview questionnaire, which was attached to the incident / accident report dated 07/28/10, revealed a statement from an unknown employee stating the oncoming RN found the antibiotic hanging and flushed the line (port-a-cath) with normal saline and [MEDICATION NAME] flush, and the physician was notified. Review of the nurses' notes, dated 07/28/10, revealed the physician was notified, but no directives from the physician to flush intravenous site (port-a-cath) were found. Review of the physician's orders [REDACTED]. On 11/03/10 at 3:00 p.m., an interview with the director of nursing (DON - Employee #106) revealed he agreed the port-a-cath should not have been flushed without a physician's orders [REDACTED]. .",2014-03-01
11397,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2010-11-03,441,D,,,3TTH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of the facility's infection control policies / procedures, review of the daily census report, and staff interview, the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection, as evidenced by improper cohorting of a resident with Methicillin-resistant Staphylococcus aureus (MRSA) with a compromised resident. One (1) of thirteen (13) residents on the sample was affected. Resident identifier: #13. Facility census: 108. Findings include: a) Resident #13 Review of Resident #13's medical record revealed she had been cohorted in a room with Resident #82, who was positive for MRSA since 10/29/10. Review of the daily census report revealed Resident #13 was moved to another room on 11/01/10. Review of the physician's orders [REDACTED]. Resident #13 was receiving the following treatments: ""Cleanse left lower leg with soap and water. Apply [MEDICATION NAME] cream, [MEDICATION NAME], and netting 2x per day on 7-3 and 11-7. Check placement QS. - NS, DS Everyday."" and ""Cleanse right lower leg with soap and water. Apply [MEDICATION NAME], and netting 1 time per day 7-3. Check placement QS. - DS Everyday."" Review of the facility's infection control policies / procedures revealed a resident with MRSA ""may be placed with a 'low risk' individual. Low risk means that the resident would not be clinically compromised. Definition of non-compromised resident is one who does not have surgical or other wound / open area."" An interview with the director of nursing (DON - Employee #106), on 11/03/10 at 1:20 p.m., revealed he did not feel that Resident #13 was ""low risk"",and he further stated the proper protocol would have been to place Resident #82 on contact precautions, remove Resident #13 from that room, and contact the physician.",2014-03-01
11398,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2010-11-23,333,D,,,D3L711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure residents were free of significant medication errors, when a resident's [MEDICATION NAME] (an anticoagulant) was not administered in accordance with physician's orders [REDACTED]. This was found for one (1) of six (6) records reviewed. Resident identifier: #99. Facility census: 128. Findings include: a) Resident #99 The medical record of Resident #99, when reviewed on 11/22/10 at 2:00 p.m., revealed this [AGE] year old woman had resided in the facility since 07/24/09 and was receiving [MEDICATION NAME] therapy for [MEDICAL CONDITION]. ([MEDICATION NAME] dosage is regulated based upon laboratory testing results designed to measure the blood clotting time and blood clotting factor.) Resident #99 was ordered a dosage of [MEDICATION NAME] for 1.5 mg by mouth every other day, alternating with [MEDICATION NAME] 3.0 mg by mouth every other day on 09/01/10. She was found to be stable on this dosage until lab results, dated 10/25/10, were elevated. A new order was written on 10/27/10, for [MEDICATION NAME] 3.0 mg by mouth on Day 1, then 1.5 mg by mouth on Days 2 and 3 on a repeating cycle, thus lowering the overall dosage. Documentation on the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 11/01/10, the monthly recapitulation (recap) of physician's orders [REDACTED]. Consequently, the [MEDICATION NAME] orders on the November 2010 MAR indicated [REDACTED]. The physician had ordered on [DATE] (when the dosage was lowered) that a repeat lab test be conducted in two (2) weeks, because of the elevated results observed on the 10/25/10 test. When the lab results were obtained on 11/10/10, they were still elevated, and the error was apparently recognized. The dosage was subsequently changed back to conform with the physician's orders [REDACTED]. The MAR for November 2010 confirmed Resident #99 received [MEDICATION NAME] per the 10/27/10 order on 11/10/10 through 11/30/10. The record revealed Resident #99 received the wrong dosage of the [MEDICATION NAME] for nine (9) days, with the potential for increased bleeding. - Interview with the facility's director of nursing (DON - Employee #17, on 11/23/10 at 11:20 p.m., confirmed the dosage of [MEDICATION NAME] administered to Resident #99 was incorrect for the first nine (9) days of November 2010. She indicated she would conduct further investigation and return to continue the discussion. On 11/23/10 at 11:27 a.m., the DON returned with a medication error report that had been completed by the facility on 11/10/10, confirming the conclusion reached during the initial record review. The medication error report stated Resident #99 received the incorrect dose for ""approx (sic) 9 days."" In response to the question ""Could the error have endangered the life or welfare of the patient?"" was checked ""yes"". Under ""Explain"" was written: ""Increased (arrow pointing up) bleeding risk.""",2014-03-01
11399,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2009-01-22,278,D,,,FRRZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident observation, and staff interview, the facility failed to ensure resident assessment information was accurate for one (1) of fifteen (15) sampled residents. Resident #61's medical record indicated a history of [MEDICAL CONDITIONS] with right-sided [MEDICAL CONDITION]. An abbreviated quarterly minimum data set assessment (MDS), with an assessment reference date of 09/10/08, indicated the resident did not have any limitations in range of motion or voluntary movement to his right arm and hand. Resident identifier: #61. Facility census: 89. Findings include : a) Resident #61 Resident #61 was observed and interviewed at 2:45 p.m. on 01/21/09, at which time he was noted to have a contracture and paralysis of the right hand. Resident #61 reported he had a stroke several years ago and did not have function of his right arm and hand. Medical record review, on 01/22/09 at 10:45 a.m., revealed the resident had a history of [REDACTED]. On 01/21/09 at 10:45 a.m., the MDS coordinator (Employee #98) was interviewed. The MDS coordinator provided the resident's most recent quarterly MDS, a significant change in status MDS, and the current care plan. Review of Section G4 of the MDS dated [DATE], revealed the information contained in this section was incorrect; the assessment indicated the resident had no limitation in function and voluntary movement to his arm or hand. The resident did have functional limitations of his right arm and hand due to post-[MEDICAL CONDITION] paralysis. .",2014-03-01
11400,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2009-01-22,241,D,,,FRRZ11,"Based on observation and staff interview, the facility failed to ensure care was promoted in a manner and in an environment that maintained the dignity of two (2) of fifteen (15) sampled residents. Resident #78 was observed in bed prior to having received morning care, while the maintenance man was painting the wall in the resident's room and was not interacting with the resident. Resident #86 was observed in a public area of the facility, crying and begging for help, and the resident's dentures were laying on her chest. Resident identifiers: #78 and #86. Facility census: 89. Findings include: a) Resident #78 On 01/20/09 at 8:15 a.m., observation found maintenance staff was painting the wall in this resident's room; the maintenance man was not engaging the resident in any conversation. The resident was still in bed, no morning care had been provided, and breakfast had not been served at this time. This resident should have been moved to another area of the facility after providing morning care and breakfast, and prior to the room being painted. During an interview on 01/21/09 at 3:30 p.m., the director of nursing (DON - Employee #62) agreed maintenance should not have painted in the resident's room at that time. b) Resident #86 On 01/20/09 at 2:10 p.m., observation found this resident was sitting in a wheelchair in the front lobby at the nurse's station. The resident was crying and begging this surveyor to help her, and her dentures were laying on her chest. Further observation found staff at the nurse's station and walking past the resident, paying no attention to the condition the resident was in. During an interview on 01/21/09 at 3:30 p.m., the DON agreed the resident should have been removed from the public area and the resident's discomfort assessed. .",2014-03-01
11401,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2009-01-22,279,D,,,FRRZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop comprehensive care plans to include hospice services and review and revise a care plan for three (3) of fifteen (15) sampled residents. Residents #78 and #28 were receiving hospice services and the comprehensive care plan failed to include the services to be provided by hospice. A care plan had been developed for Resident #42 which did not accurately describe the resident's pain and had not been revised when reviewed. Resident identifiers: #78, #28, and #42. Facility census: 89. Findings include: a) Resident #78 Medical record review, on 01/20/09, revealed this resident had a [DIAGNOSES REDACTED]. Review of the comprehensive care plan, revised in November 2008, revealed the care plan did not include the services to be provided by hospice. The resident's comprehensive care plan failed to have an integrated care plan with hospice which included the services provided by hospice with interventions describing who would do them and when they would be done. During an interview on 01/22/09 at 2:00 p.m., the minimum data set assessment (MDS) coordinator confirmed the comprehensive care plan and the hospice care plan was not integrated ensuring continuity of care by both facility and hospice staff. b) Resident #42 Medical record review, on 01/20/09, and a review of the comprehensive care plan it was revealed during the review of the activity care plan this resident indicated she could not leave her room due to pain. During further review of the activity care plan dated September, 2008, under the heading of Problems / Strengths was a quote ""I want something to do, but I can't leave my room due to pain and need to be comfortable. I lie in bed most of the day."" During a review of the estimated date of the goals it was discovered this activity plan had been reviewed on 01/19/09 with no changes made. During interviews on 01/21/09 at 4:00 p.m., the director of nursing (DON) and the MDS coordinator revealed this resident did not communicate well and would not be able to verbalize in this manner, and this statement and care plan did not accurately describe the resident's pain was not accurate. c) Resident #28 A review of the resident's medical record revealed [REDACTED]. A review of the resident's care plan revealed the hospice care plan was not integrated with the facility's care plan for the resident. .",2014-03-01
11402,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2009-01-22,309,D,,,FRRZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure care and services were provided in a manner to maintain the highest practicable physical well-being for one (1) of fifteen (15) sampled residents. Resident #78 had a medical history of [REDACTED]. Resident identifier: #78. Facility census: 89. Findings include: a) Resident #78 On 01/20/09 at 8:15 a.m., observation found maintenance staff was painting the wall in this resident's room. The resident was still in bed, no morning care had been provided, and breakfast had not been served at this time. The room smelled strongly of paint. Medical record review revealed Resident #78's [DIAGNOSES REDACTED]. This practice put the resident at risk for respiratory distress and can contribute to a poor appetite. This resident should have been moved to another area of the facility prior to the room being painted. During an interview on 01/21/09 at 3:30 p.m., the director of nursing (DON - Employee #62) agreed the room should not have been painted while the resident was in the room. .",2014-03-01
11403,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2009-01-22,441,D,,,FRRZ11,"**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 sanitary environment to prevent the spread of infections in the facility during treatments provided to residents with known infections. Observation of the treatment nurse (Employee #2) during a treatment found her kneeling beside the resident's bed while applying a dressing to Resident #86's wound; she contaminated her uniform by kneeling on the floor, as she wore no protective clothing during this dressing change. This resident (#86) had a history of [REDACTED]. Resident identifier: #86. Facility census: 89. Findings include: a) Employee #2 During treatment administration on 01/21/09 at 1:10 p.m., observation found the treatment nurse changing a dressing to a pressure sore on Resident #86's coccyx. The treatment nurse knelt on the floor beside the resident's bed while applying the dressing. Although the nurse used universal precautions during the procedure, she did not don protective clothing. By kneeling on the floor, the contaminated her uniform. Medical record review revealed the resident had a history of [REDACTED]. Observation found, upon entering the resident's room, a sign advised visitors of the need for contact isolation and to see the nurse before entering the room. During an interview on 01/21/09 at 4:15 p.m., the director of nursing (DON) agreed the treatment nurse should not have been on the floor of this resident's room while changing the dressing. .",2014-03-01
11404,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2009-01-22,225,D,,,FRRZ11,"Based on review of the facility's complaint / grievance log and staff interview, the facility did not ensure two (2) of twenty (20) sampled complaints / grievances containing allegations of neglect were immediately reported to the appropriate State agencies. Resident identifiers: #22 and #96. Facility census: 95. Findings include: a) Resident #22 On 01/01/09, Resident #22 alleged, ""he did not have a pad for his bed. CNA (named by resident) was asked to get one for his bed. The CNA told him no, that they took them out of the building. He reported that he had to sleep on a bath blanket which wrinkled and caused a sore to his buttocks."" The facility's investigation revealed cloth pads were to be available for this resident, and the nurse had assessed the resident after he was placed on the bath blanket and found the resident's buttocks were more red and irritated. An interview with the social worker, on 01/20/09 at 10:00 a.m., revealed the facility had not reported this allegation of neglect to the appropriate State agencies. b) Resident #96 On 11/19/08, Resident #96 alleged, ""Resident had call light on for 50 minutes and roommate also call light on also and that fresh water on the 2:00 p.m. to 10:00 p.m. shift was not provided."" The facility's investigation revealed the nursing assistant involved was identified and education would be provided for answering call lights and providing fresh water to residents. An interview with the social worker, on 01/20/09 at 10:00 a.m., revealed the facility had not reported this allegation of neglect to the appropriate State agencies. .",2014-03-01
11405,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2010-11-02,279,E,,,QWDA11,". Based on observation, record review, and staff interview, the facility did not develop care plans for six (6) of seven sampled residents to provide justification for the residents to sit in the facility hallways in front of the nursing station to eat their meals. Resident identifiers: #19, #6, #26, #46, #45, and #44. Facility census: 75. Findings include: a) Residents #19, #6, #26, #46, #45, and #44 Observations, on 11/01/10 beginning at 12:15 p.m., found the above-identified six (6) residents sitting in front of the nursing stations in the hallways eating their lunch. Some of the residents were able to eat without assistance, and others were being fed by the staff. Four (4) residents (#6, #26, #46, and #45) were observed on the South hall, and two (2) residents (#19 and #44) were observed on the North hall. An interview with the director of nursing (DON), on 11/01/10 at 12:15 p.m., revealed the residents wanted to eat in the hallway in front of each nursing station. She further stated that some of the residents were unable to make the decision to eat in the hallway and the legal representative requested that the resident eat in the hallway in front of the nursing station. The DON also stated all of these residents had a care plan identifying the reason for each resident eating meals in this location. A review of the care plans these residents found no mention of eating their meals in the hallways. .",2014-03-01
11406,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2010-11-02,309,D,,,QWDA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility did not ensure one (1) of seven (7) sampled residents did not receive the influenza vaccine in accordance with the legal representative's wish to decline the vaccine due to an allergy. Resident identifier: #19. Facility census: 75. Findings include: a) Resident #19 Record review revealed a facility consent form titled ""Vaccine Administration Authorization"", upon which was recorded either acceptance or refusal to receiving the influenza vaccine, indicated that Resident #19's legal representative declined administration of the influenza vaccine, because the resident was allergic to it. On 10/21/10 at approximately 6:30 a.m., a nurse administered the influenza vaccine to the resident contrary to the wishes of the legal representative. At 8:00 a.m. on 10/21/10, Resident #19 became unconscious and was transferred to the hospital and admitted . Review of hospital records for Resident #19 revealed, ""[AGE] year old female nursing home resident presented to the hospital after having two [MEDICAL CONDITION]. Patient had received [MEDICATION NAME] at the nursing home after getting the flu vaccine which she is allergic to. Patient had recently been taken off [MEDICATION NAME] which she was on for a number of years for agitation. Two weeks prior to having [MEDICAL CONDITION], [MEDICATION NAME] was discontinued abruptly and she was started on [MEDICATION NAME]. Patient was admitted and we restarted [MEDICATION NAME]."" The hospital obtained an electrocardiogram (EKG), serial cardiac enzymes, CT of the brain, electroencephalogram (EEG), a chest X-ray, and blood work, and all results were within normal limits. An interview with the assistant director of nursing (ADON - Employee #32), on 11/01/10 at 1:30 p.m., revealed she was called to Resident #19's room after the influenza vaccine was administered to the resident by mistake at approximately 6:30 a.m. on 10/21/10. She immediately told the nurse to call the physician to obtain an order for [REDACTED]. The family of the resident had told her the resident was not allergic to eggs but was allergic to a preservative that was in the influenza vaccine and that she could not have the vaccine. The ADON also described the procedure the facility completed before administering the influenza vaccine, which involved gathering all consent forms for the vaccine and reviewing any allergies [REDACTED]. On the morning of 10/21/10, the nurse and the staff development coordinator had assembled the consent forms. The nurse had not reviewed the physician orders [REDACTED]. An interview with the director of nursing (DON), on 11/01/10 at 2:00 p.m., revealed, the nurse who administered the influenza vaccine to Resident #19 was no longer working at the facility. She further stated the nurse had not looked at the authorization form that indicated the resident was not to receive the vaccine and the nurse did not review the resident's physician orders [REDACTED]. An interview with the current staff development coordinator (Employee # 82), on 11/02/10 at 10:30 a.m., revealed he and another nurse had gathered vaccine administration authorization forms and the nurse was going to give the vaccine to the residents. The former staff development had asked them if they had reviewed the physician orders [REDACTED]. The nurse told him she had not looked at the physician orders [REDACTED]. He further stated the nurse apparently had not looked at the authorization form, because the resident received the vaccine and the authorization form indicated a refusal for the vaccine. A telephone interview with the facility's medical director, on 11/02/10 at 10:30 a.m., revealed he was not certain why the resident had the two (2) [MEDICAL CONDITION] after the flu vaccine was administered. The physician further reported he had never seen an influenza vaccine cause [MEDICAL CONDITION].",2014-03-01
11407,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2010-11-11,244,E,,,VERC11,". Based on review of resident council meeting minutes and staff interview, the facility failed to act upon a grievance made during a resident council meeting. On 09/27/10, residents expressed concerns regarding call lights not being answered during the midnight shift on Unit 4. This concern was not addressed by facility personnel. This practice had the potential to affect twenty-six (26) of twenty-six (26) residents who resided on Unit 4. Facility census: 107. Findings include: a) Review of the facility's 09/27/10 resident council meeting minutes, on 11/11/10, revealed residents expressed a concern regarding call lights not being answered on the midnight shift on Unit 4. Further review of the minutes revealed no evidence this concern had been acted upon by facility personnel. On 11/11/10 at 1:00 p.m., the administrator (Employee #16) was asked to provide evidence this issue had been addressed by the facility. At 1:10 p.m., Employee #16 reported the concern had not been acted upon as required.",2014-03-01
11408,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-11-11,157,D,,,50T311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, and staff interview, the facility failed to notify the physician of a potential need to alter treatment for one (1) of six (6) sampled residents whose closed record was reviewed. Resident #119 was admitted to the facility on [DATE] following a prolonged hospital stay beginning on 09/09/10 during which she received treatment for acute [MEDICAL CONDITION] (ARF), and her discharge orders from the hospital included [MEDICATION NAME] inhalation treatments every four (4) hours (at regular intervals six (6) times a day). According to documentation on her October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Of these twenty-five (25) missed doses, coding on the MAR indicated [REDACTED]. Medical record found no documentation reflecting either the physician or the physician extender had been notified of the resident refusing these treatments. This notification would have provided the physician an opportunity to change / modify treatment for this resident. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 Review of Resident #119's closed medical record revealed this [AGE] year old female was admitted to the nursing facility on 09/30/10 following a prolonged hospital stay beginning on 09/09/10 during which she received treatment for ARF. Her discharge orders from the hospital included the administration of [MEDICATION NAME] inhalation treatments every four (4) hours. Review, on 11/10/10, of Resident #119's October 2010 MAR indicated [REDACTED]. According to documentation on her October 2010 MAR, between 10/01/10 and 10/11/10, Resident #119 did not receive twenty-five (25) of sixty-six (66) scheduled inhalation treatments. Of these twenty-five (25) missed doses, coding on the MAR indicated 2 = Drug Refused""). Review of the resident's care plan, which had been initiated on 10/07/10, revealed the following problem statement: ""Short of breath / difficulty breathing related to: [MEDICAL CONDITION]."" Interventions to address this problem included: ""Provide nebulizer treatments as ordered."" Review of the facility's policy titled ""Notification of Refused or Held Medications / Treatments"" (policy #F-005, dated 10/15/05) found under the heading procedure: ""A. When a medication / treatment cannot be administered as ordered, the prescriber must be notified."" In an interview on 11/10/10 at 3:30 p.m., the director of nursing (DON - Employee #81) confirmed that nursing staff should have notified the physician that this resident was refusing her inhalation treatments at times. .",2014-03-01
11409,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-11-11,225,D,,,50T311,". Based on review of information from a criminal background check, staff interview, and review of a 2004 newsletter issued by the Office of Health Facility Licensure and Certification (OHFLAC) to all Medicare / Medicaid nursing facilities, the facility failed to ensure a West Virginia State Police background check was completed prior to hire for one (1) of one (1) background checks reviewed. Employee #123, a certified nurse practitioner (CNP), had been employed at this facility since May 2010, and no criminal background check by the West Virginia State Police had been completed as required by OHFLAC. Employee identifier: #123. Facility census: 118. Findings include: a) Employee #123 During a complaint investigation conducted at the facility between 11/08/10 and 11/11/10, it was discovered the facility had employed Employee #123 as a CNP since May 2010. Review of Employee #123's personnel record revealed the pre-employment screening conducted on this individual did not include a criminal background check by the West Virginia State Police in an effort to uncover a personal history of criminal convictions that may indicate this individual was unsuited for employment in a nursing facility. In an interview on the afternoon of 11/09/10, the facility's administrator (Employee #53) confirmed a criminal background check had not been conducted through the West Virginia State Police prior to hiring Employee #123. Review of a newsletter (dated November 2004), which had been distributed by OHFLAC to all Medicare / Medicaid certified nursing facilities in West Virginia, revealed the following directive: ""... Regarding criminal background checks, both the State licensure rule and the Federal Medicare / Medicaid certification requirements mandate screening of applicants for employment in a nursing home or nursing facility. The licensure rule specifically requires nursing homes to conduct a 'criminal conviction investigation' on all applicants; the certification requirements require that nursing facilities 'must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law'; facilities are expected to 'make reasonable efforts to uncover information about any past criminal prosecutions'. To satisfy these requirements, OHFLAC will accept nothing less than a statewide criminal background check on all applicants. Individuals for whom criminal background investigations have been initiated may begin work at the facilities pending satisfactory outcomes of the checks. ..."" .",2014-03-01
11410,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-11-11,281,D,,,50T311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, and staff interview, licensed nursing staff at the facility failed to follow facility policy regarding the administration of aerosolized medication to one (1) of six (6) sampled residents whose closed record was reviewed. According to her October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to facility policy, licensed nursing staff was to collect and record physical assessment data regarding the resident's respiratory status prior to and following the administration of an aerosolized medication and the resident's response to each treatment after administration was complete. Review of documentation recorded in the resident's nursing notes and on the medication administration records (MARs) found no evidence that any physical assessment data regarding the resident's respiratory status had been collected and recorded either prior to and after each nebulizer treatment, and there was no documentation recorded describing the resident's response to each treatment. Staff interviews confirmed these assessments were not being done, thus not meeting professional standards of quality. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 Review of Resident #119's closed medical record revealed this [AGE] year old female was admitted to the nursing facility on 09/30/10 following a prolonged hospital stay beginning on 09/09/10 during which she received treatment for [REDACTED]. Review, on 11/10/10, of Resident #119's October 2010 MAR indicated [REDACTED]. - Review of the resident's care plan, which had been initiated on 10/07/10, revealed the following problem statement: ""Short of breath / difficulty breathing related to: [MEDICAL CONDITION]."" Interventions to address this problem included: ""Administer medication as ordered. ... Notify physician of increased complaints of difficulty in breathing. Obtain oxygen saturation levels. Obtain vital signs. Provide nebulizer treatments as ordered."" - Review of documentation recorded in the resident's nursing notes and on the September and October MARs found no evidence that any physical assessment data regarding the resident's respiratory status had been collected and recorded either prior to and after each nebulizer treatment. - Review of the facility's policy ""Aerosolized Medication (Neb Med)"" (with a revision date of May 2002) found the following under Item #4 under guidelines: ""h. Assess the Resident ""(1) Note the resident's skin color and temperature, skin characteristics (warm and dry vs. cold and clammy; elastic vs. [MEDICAL CONDITION]), pattern and effort of breathing, ability to take a deep breath and cough and quality of breath sounds. If medication is being given for wheezing, note quality and intensity so as to be prepared to document post-[MEDICATION NAME][MEDICATION NAME] effects. ""(2) Check respiratory rate prior to treatment."" According to the policy, after the nebulizer treatment ceases, the following steps were to be completed: ""n. Assess the resident to determine therapeutic outcome. ... ""r. Document medication, [MEDICATION NAME], dose, pulse and breath sounds before and after the treatment, O2 (oxygen) liter flow, cough, color and consistency of sputum, resident (sic) subjective response and any adverse reactions and action taken."" - During an interview on 11/10/10 at 3:30 p.m., the director of nursing (DON - Employee #81) revealed that any documentation related to the implementation of this policy would be recorded in the resident's nursing notes. - During an interview on 11/10/10 at 4:15 p.m., the licensed practical nurse (LPN - Employee #79), who initialed Resident #119's MAR indicated [REDACTED]#119's respiratory status before and after administering these nebulizer treatments. .",2014-03-01
11411,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-11-11,309,G,,,50T311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed medical record review, review of facility policies and procedures, review of records from an area hospital and the ambulance service, and staff interviews, the facility failed to ensure one (1) of six (6) sampled residents received care and services necessary to attain or maintain her highest level of physical well-being and to avoid physical harm. Resident #119, who was admitted to the facility on [DATE] for Medicare-covered skilled nursing and rehabilitation services to include observation and assessment of her care plan, began exhibiting an acute change in condition. The facility's licensed nursing staff failed, in accordance with the facility's policy and procedures, to provide on-going assessment / monitoring, administer interventions when ordered by the physician extender, and/or obtain timely medical intervention as the resident's condition continued to decline. A registered nurse (RN) first recorded in the medical record that Resident #119 was lethargic at 5:10 p.m. on [DATE]; prior to that time, the resident had been noted to be free of signs and symptoms of distress and discomfort. A licensed practical nurse (LPN) first recorded in the medical record, in an entry dated 5:00 a.m. on [DATE], Resident #119 had vomited three (3) times during the 11:00 p.m. to 7:00 a.m. (,[DATE]) shift. After this entry, there was no evidence of any physical assessment data having been contemporaneously collected and recorded in the resident's medical record related to the resident's level of consciousness (LOC), vital signs, respiratory status, and/or vomiting until the certified nurse practitioner (CNP - Employee #123) employed by the facility evaluated the resident and recorded a progress note that was electronically signed at 11:59 a.m. on [DATE]. In addition to the absence of evidence that physical assessment data was being contemporaneously collected and recorded with respect to Resident #119's acute change in condition, routine assessment data of the resident's respiratory status were not collected every four (4) hours before and after each inhalation treatment that had been administered at 8:00 a.m., 12:00 p.m., and 4:00 p.m. on [DATE]. No interventions were ordered to address the resident's vomiting until about 1:00 p.m. on [DATE], when, according to information contained in a late entry recorded a week later by the desk nurse (Employee #19) on [DATE] at 3:27 p.m., Employee #19 received orders from the CNP for [MEDICATION NAME] (an antiemetic to treat nausea / vomiting), [MEDICATION NAME] (a protein pump inhibitor to treat [MEDICAL CONDITION] reflux), and [MEDICATION NAME] (a stool softener). Once ordered, there was no evidence to reflect any of these medications was administered. According to information contained in a late entry recorded on [DATE] at 3:27 p.m. by Employee #19, after the CNP reviewed the results of some labs that had been sent to the facility, to start intravenous (IV) fluids, start supplemental oxygen, administer a stat dose of [MEDICATION NAME] (an antibiotic), and obtain a chest x-ray for possible pneumonia, Employee #19 received a second set of orders from the CNP at about 2:00 p.m. on [DATE]. According to information contained in a late entry recorded on [DATE] at 12:35 p.m. by the nurse assigned to care for Resident #119 from 7:00 a.m. to 7:00 p.m. on [DATE] (Employee #79), she started an IV shortly thereafter, applied supplemental oxygen at about 2:45 p.m., and collected physical assessment data at 4:00 p.m. noting the resident was alert with confusion, lethargic, with decreased lung sounds, with [MEDICAL CONDITION] in lower extremities, and with an oxygen saturation level of 88%. However, there was no contemporaneous documentation in the nursing notes related to insertion of the IV and no evidence of any physical assessment data having been contemporaneously collected and recorded in the resident's medical record related to the resident's LOC, vital signs, respiratory status, and/or vomiting after the entry made by the CNP at 11:59 a.m. earlier that morning. Interviews with nursing assistants (Employees #59, #54, and #67) revealed the resident continued to vomit on [DATE] during both the 7:00 a.m. to 3:00 p.m. (,[DATE]) shift and the 3:00 p.m. to 11:00 p.m. (,[DATE]) shift. However, there was no evidence of any physical assessment data having been contemporaneously collected and recorded in the resident's medical record related to the resident's LOC, vital signs, respiratory status, and/or vomiting after the entry made by the CNP at 11:59 a.m. earlier that morning. Interviews with staff revealed Employee #54, at the start of her ,[DATE] shift, found Resident #119 had vomited a brownish-colored liquid on her clothes, and she and another nursing assistant (Employee #67) cleaned her up. Employee #54 went to the nurse's station and told Employee #79 that Resident #119 had vomited. Employee #67 reported that, at that time, the resident was talking and her breathing sounded ""OK"". About thirty (30) minutes later, the resident vomited again. Employee #67 reported that, after Resident #119 vomited a third time, the resident started gurgling and was struggling to breathe, and she grabbed Employee #67 by the arm. According to Employee #67, Employee #54 left the room saying she was going to find out if the nurse would suction her. Interview with Employee #54 revealed she had gone to the nurse's station to ask the nurse if Resident #119 was a full code, and she told the nurse she thought the resident was dying. According to Employee #67, two (2) nurses then came to the room and ""looked at the resident, then turned around and left the room"", and one (1) of the nurses stated, ""I'm sending her out of here. I'm leaving at 7:00."" There was no evidence that interventions were provided in an effort to clear the resident's airway. According to information contained in late entries recorded by Employees #19 and #79, the resident's IV stopped flowing. At 5:00 p.m., an ambulance crew was called in the re-start the IV. The ambulance crew arrived and, at 6:20 p.m., was attempting to restart an IV. Employee #79 recorded, in her late entry on [DATE] at 12:35 p.m., that at 6:20 p.m., Resident #119 was alert with labored respirations and had vomited tea-colored fluid; in the same late entry, Employee #79 recorded that, at 6:40 p.m., a nurse aide came to her to ask about the resident's code status, at which time Resident #119 was having difficulty breathing, with decreased LOC, no response to verbal stimuli, raspy breath sounds, and ""eyes not reactive to light accommodation"". However, again, there was no evidence of any physical assessment data having been contemporaneously collected and recorded in the resident's medical record related to the resident's LOC, vital signs, respiratory status, and/or vomiting after the entry made by the CNP at 11:59 a.m. earlier that morning. The resident was transported from the facility at 7:22 p.m. on [DATE] to the hospital, where she expired at 9:50 p.m. that same evening; her cause of death was listed on the death certificate as [MEDICAL CONDITION] due to aspiration due to [MEDICAL CONDITION]. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 1. Review of Resident #119's closed medical record revealed this [AGE] year old female resident was initially admitted from the hospital to the nursing facility at 1:08 p.m. on [DATE], with [DIAGNOSES REDACTED]. Further review of her record revealed that, during her extended hospital stay prior to admission to the facility, she was treated for [REDACTED]. According to multiple entries in the nursing notes made contemporaneously on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], the resident was admitted for the purpose of receiving Medicare-covered skilled services for observation and assessment of her care plan and rehabilitative therapies. According to her admission minimum data set assessment, with an assessment reference date of [DATE], she was alert, could hear with minimal difficulty, had clear speech, was usually understood when she verbally expressed ideas to others, was usually able to understand what was said to her when spoken to, and was able to participate in the interviews during the assessment process. She was totally dependent upon staff for bed mobility, transferring, and locomotion, she required extensive physical assistance with dressing, toilet use, and personal hygiene, and she required set-up assistance with eating. -- 2. Review of Resident #119's nursing notes found a contemporaneous entry, dated [DATE] at 3:00 a.m., stating, ""Skilled services continue. (Symbol for 'no') S/S (signs / symptoms) of distress or discomfort @ this time. Meds taken /s (without) difficulty. In bed /c (with) eyes closed. Call light in reach."" The next consecutive entry, dated [DATE] at 5:10 p.m., stated, ""N/O (new order) noted. CBC (complete blood count), BMP (basic metabolic panel), sed (sedimentation) rate d/t (due to) lethargy. Family aware."" Between 3:00 a.m. and 5:10 p.m. on [DATE], there was no documentation in the nursing notes of any observations and/or nursing assessments of Resident #119's health status completed by the facility's licensed nursing staff. The next consecutive entry in the nursing notes, dated [DATE] at 5:00 a.m., stated, ""Resident vomited x 3 this shift. Will monitor."" This is the first mention in the resident's record of her having vomited. There was no description of the characteristics of the emesis (e.g., color, quantity, consistency, etc.), and no vital signs (e.g., temperature, blood pressure, heart rate, respirations) were recorded either in the nursing notes or a separate vital signs flow sheet. There was no documentation to indicate nursing staff notified the resident's responsible party, attending physician, or the CNP employed by the facility, of this change in the resident's condition. There was also no discussion of whether the resident remained lethargic, as had been noted at 3:00 a.m. on [DATE] and for which the CNP had previously ordered lab studies. The next consecutive entry in the nursing notes, dated [DATE], at 10:00 a.m., stated, ""Weekly care team IDT (interdisciplinary team) review: Tylenol Q 8 ATC x 7 days. F/U (follow-up appointment) Dr. (name) on [DATE]. [MEDICATION NAME] & [MEDICATION NAME] for dementia. OT (occupational therapy), PT (physical therapy) as ordered. ST (speech therapy) as ordered. [MEDICATION NAME] to groin & breasts. Dry drsg (dressing) to Lt (left) knee."" This interdisciplinary note was recorded by an RN, but it did not contain any mention of acute changes in condition exhibited by the resident in the previous twenty-four (24) hour period (e.g., lethargy or vomiting). The next consecutive entry in the nursing notes, dated 1:05 p.m. on [DATE], stated, ""N.O. (new order) Bilateral heels off bed /w (with) pillows @ (at) all x's (times) for prevention. N.O. Sure Prep to bilateral heels 2x's QD (twice daily) on NS (night shift), DS (day shift) for prevention."" This entry was not signed by its author. The next consecutive entry in the nursing notes, dated [DATE] at 4:-0 p.m. (the exact time of the entry was illegible), stated, ""N/O for chest x-ray d/t cough & congestion, Attempts x 3 to call MPOA (medical power of attorney) /s success. This entry was recorded by Employee #19, an LPN. There was no mention of the resident's level of consciousness with respect to whether she remained lethargic, there was no mention of whether she had continued to vomit, and even though this was the first mention of the resident having exhibited any cough or congestion, there was no quantitative or qualitative description of her respiratory status (e.g., rate of respirations, blood oxygen saturation level, presence or absence of adventitious sounds in her lung fields, difficulty or ease of breathing, etc.) or her vital signs. The next consecutive entry in the nursing notes, made by LPN Employee #19 and dated [DATE] at 5:25 p.m., stated, ""QMI (name of mobile imaging company) on site; CXR (chest x-ray) done."" The next consecutive entry in the nursing notes, made by Employee #19 and dated [DATE] at 7:00 p.m., stated, ""MPOA notified of decline; wish (sic) to send to TMH (area hospital)."" The next consecutive entry in the nursing notes, made by Employee #19 and dated [DATE] at 7:22 p.m., stated, ""KCA (local ambulance service) on site to transport to KCA (sic) /c (with) accompanied (sic) on ii (2) attendants."" The next consecutive entry in the nursing notes, dated [DATE] at 8:00 a.m., stated, ""Expired @ TMH ER (emergency room ) @ 9:50 p.m. [DATE]."" This entry was then followed by a series of late entries recorded at 12:35 p.m. on [DATE] by Employee #79 (the LPN assigned to care for Resident #119 from 7:00 a.m. to 7:00 p.m. on [DATE]), which was then followed by another series of late entries recorded by Employee #19 (the desk nurse who worked on [DATE]) at 3:27 p.m. on [DATE] a week after the resident had expired. (See also citation at F514.) -- 3. In addition to the absence of evidence that physical assessment data was being contemporaneously collected and recorded with respect to Resident #119's acute change in condition, routine assessments of the resident's respiratory status were not performed every four (4) hours before and after each inhalation treatment that had been administered on [DATE]. (See also citation at F281.) Review, on [DATE], of Resident #119's [DATE] MAR indicated [REDACTED]. Review of the resident's care plan, which had been initiated on [DATE], revealed the following problem statement: ""Short of breath / difficulty breathing related to: [MEDICAL CONDITION]."" Interventions to address this problem included: ""Administer medication as ordered. ... Notify physician of increased complaints of difficulty in breathing. Obtain oxygen saturation levels. Obtain vital signs. Provide nebulizer treatments as ordered."" Review of documentation recorded in the resident's nursing notes and on the October MAR found no evidence that any physical assessment data regarding the resident's respiratory status had been collected and recorded either prior to and after each nebulizer treatment. Review of the facility's policy ""Aerosolized Medication (Neb Med)"" (with a revision date of [DATE]) found the following under Item #4 under guidelines: ""h. Assess the Resident ""(1) Note the resident's skin color and temperature, skin characteristics (warm and dry vs. cold and clammy; elastic vs. [MEDICAL CONDITION]), pattern and effort of breathing, ability to take a deep breath and cough and quality of breath sounds. If medication is being given for wheezing, note quality and intensity so as to be prepared to document post-[MEDICATION NAME][MEDICATION NAME] effects. ""(2) Check respiratory rate prior to treatment."" According to the policy, after the nebulizer treatment ceases, the following steps were to be completed: ""n. Assess the resident to determine therapeutic outcome. ... ""r. Document medication, [MEDICATION NAME], dose, pulse and breath sounds before and after the treatment, O2 (oxygen) liter flow, cough, color and consistency of sputum, resident (sic) subjective response and any adverse reactions and action taken."" During an interview on [DATE] at 3:30 p.m., the director of nursing (DON - Employee #81) revealed that any documentation related to the implementation of this policy would be recorded in the resident's nursing notes. During an interview on [DATE] at 4:15 p.m., the LPN (Employee #79) who initialed Resident #119's MAR indicated [REDACTED]#119's respiratory status before and after administering each of these nebulizer treatments. -- 4. Review of the run sheet completed by personnel from the emergency medical services (EMS) that transported Resident #119 from the facility to the hospital on the evening of [DATE] revealed, under pertinent findings, the primary signs and symptoms necessitating EMS was ""Respiratory Arrest""; other signs and symptoms included ""Decreased LOC"". In the narrative section on page 1 of 6 was recorded, ""Patient found by staff (sic) decreased LOC (sic) Upon arrival found thw (sic) patient snoring resp 3 breaths amin (sic) ..."" Under event chronology beginning on page 3 of 6, a physical assessment by EMS personnel found her eyes / pupils were reactive to light when assessed at 1914 (7:14 p.m.) on [DATE]. At 1915 (7:15 p.m.), her B/P was ,[DATE] and her respiratory rate was 3 breaths per minute and labored with an oxygen saturation of 85%. The resident was intubated, and the ambulance left the scene at 1930 (7:30 p.m.). Her care was transferred to the ER at 1942 (7:42 p.m.) -- 5. According to notes from the hospital ER, Resident #119 arrived and was triaged at 1942 (7:42 p.m.) on [DATE]. When assessed at 1952 (7:52 p.m.), her B/P was ,[DATE], heart rate 134, respiratory rate 14, temperature 98.7 degrees F, oxygen saturation at 96%, and she was not alert. At 2041 on [DATE], a note recorded, ""Daughter states Pt is DNR (do not resuscitate) and as MPOA requests that all 'artificial life support and tx (treatment) for [MEDICAL CONDITION]' be dc'd (discontinued). (MPOA) also spoke these requests to Dr,. (name), ER attending."" Resident #119 was subsequently extubated, and she expired at 9:50 p.m. on [DATE]. -- 6. A copy of Resident #119's certificate of death, which was obtained from the hospital, revealed her time of death was 2150 (9:50 p.m.) on [DATE], and her cause of death was [MEDICAL CONDITION] due to aspiration, due to [MEDICAL CONDITION]. -- 7. Review of the facility's policy on Change of Condition of a Resident (policy # CL-,[DATE], with an effective date of "",[DATE]"") revealed the following: ""Policy Statement - It is the policy of the center to take appropriate action and provide timely communication to the resident's physician and responsible party relating to a change in condition of a resident."" ""Procedure - Action Steps ""1. The Licensed nurse determines if there has been a change in condition of a resident. (Attachment E) ""2. The Licensed Nurse notified, via telephone, the attending physician and the resident's responsible party of the specific nature of the change in condition. - The primary mode of urgent communication is by telephone. ... - The Medical Director will be contacted in the event that the attending physician is not available for consultation. - If unable to reach either the attending physician or the medical director, the resident will be transported immediately via 911, the DNS (director of nursing services) / designee will be notified. ""3. The Licensed Nurse initiates action to ensure the immediate safety of the resident. ""4. The Licensed Nurse confers with the Physician / Physician Extender to determine what actions may be necessary to meet the immediate needs of the resident. ""5. The Physician / Physician Extender providers orders to direct the care of the resident. (Attachment A) ""6. The Licensed Nurse / designee implements the physician's orders [REDACTED]. ""7. The Licensed Nurse documents in the interdisciplinary progress notes and on the 24 Hour Report of Resident change in Condition Book: (Attachment B, C, D, E) - The condition of the resident - Whom was notified and when - Care & treatment orders dictated by the physician - Implementation of physician orders - Care interventions in the resident's plan of care - Residents (sic) response to interventions."" According to page 3 of 8 of the policy, the forms to be used when implementing this procedure are as follows: - Attachment A - Physician Telephone Orders (form #,[DATE]) - Attachment B - Interdisciplinary Progress Notes (form #,[DATE]) - Attachment C - 24 Hour Report of Resident Change in Condition Book (form #,[DATE]) - Attachment D - ICP (interdisciplinary care plan) Goals and Approaches (form # ,[DATE]) - Attachment E - Change of Condition Documentation (form # ,[DATE]) Review of Resident #119's closed record found no use of the Change in Condition Documentation form, which would have prompted the licensed nurse completing the form to collect and record data under the headings objective / underlying illness / symptoms (including vital signs and food / fluid intake in the last 24-hours), general appearance (including the presence of lethargy), and physical evaluation (including a change in mental status, the presence of a cough, the presence of adventitious breath sounds, oxygen saturation levels with and without the use of supplemental oxygen, and if vomiting is present, a description). Resident #119's interdisciplinary progress notes (also known as ""nursing notes"") did not contain documentation to indicate nursing staff notified the resident's responsible party, attending physician, or the CNP employed by the facility when the resident vomited three (3) times on the ,[DATE] shift ending on the morning of [DATE] documentation to indicate the resident continued to vomit on both the ,[DATE] shift and the ,[DATE] shift of the same day. There was no ICP in her closed record addressing her acute change in condition with respect to her decreased LOC (lethargy) and vomiting. While orders were written by the physician extender (Employee #123, the CNP), not all of the orders were implemented by the licensed nurses. Review of the facility's 24 Hour Report of Resident Change in Condition Book for the time period of [DATE] through [DATE], found the first mention of Resident #119 on an undated page found between [DATE] and [DATE], which noted she was to have a CBC, BMP, and sed rate. Although there were columns under the heading of ""Change in Condition"" in which check marks could be placed to indicate such things as the presence of vomiting, there was no evidence Resident #119 was identified on the 24 Hour Report as requiring monitoring related to her vomiting, which (according to a nursing note) began on the ,[DATE] shift ending on the morning of [DATE] and which (according to staff interviews) continued through both the ,[DATE] shift and the ,[DATE] shift on [DATE]. The next mention of Resident #119 on the 24 Hour Report was an entry a the page dated [DATE], which stated, ""to (sic) ER d/t fixed pupils & severe congestion - MPOA stated, 'send (sic) her to ER.' Expired 9:50 p.m. @ ER."" The facility's licensed nursing staff did not follow the facility's policy and procedures when Resident #119 exhibited an acute change of condition. -- 8. Medical record review revealed Resident #119 was seen by the facility's CNP on [DATE], [DATE], and [DATE]. A CNP progress note dated [DATE] (and electronically signed at 1:25 p.m. on [DATE]) identified, under review of symptoms, the patient denied fever and chills and shortness of breath. Under physical examination, the CNP recorded the resident as being ""frail and alert oriented x 2"" and her lungs were clear to auscultation bilaterally. Her vital signs were assessed as follows: ""blood pressure at Left Arm while Sitting is ,[DATE] mm/Hg 96 bpm (beats per minute) regular 98.0F 139 pounds clothed."" At the end of this progress note was written: ""Resident does have discomfort during PT-family (sic) requests that Tylenol be schedules, rather thatn (sic) prn (as needed). Will schedule and observe -possible (sic) will have to order [MEDICATION NAME] prior to PT. Dementia increases difficulty in assessing resident. Comorbidities stable and resident is stable."" - A CNP progress note dated [DATE] (and electronically signed at 2:46 p.m. the same day) identified that Resident #119 presented with lethargy and ""the symptom started 7 days ago."" (Although this note indicated the lethargy started seven (7) days ago (which would have been [DATE]), there was no mention of lethargy in the CNP's progress note for [DATE] and no mention of lethargy in any of the nursing notes recorded in Resident #119's closed record during the time period from [DATE] to [DATE].) Under review of symptoms, the CNP recorded, ""The patient complained of malaise and lethargy but denied fever and chills"" and she ""denied cough"". Under physical examination, the CNP recorded Resident #119's pharynx was clear and her lungs were clear to auscultation bilaterally. Under services ordered, the CNP recorded a CBC, BMP, and RBC sed rate. At the end of the progress note was written: ""Resident appears to be stable. Will obtain labs and reevaluate. If normal labs, will consider adjusting medication."" - A CNP progress note dated [DATE] (and electronically signed at 11:59 a.m. the same day) revealed, under chief complaint, ""(Resident #119) presented with vomiting. It is described as acute. The symptom is sudden in onset. The symptom started 4 hours ago. The complaint is mild. Episodes occur in the morning. ... In addition, she presented with shortness of breath. It is described as stable. The symptom is gradual in onset. ... Patient denies apnea, cough, [MEDICAL CONDITION] and sputum production. ... Evaluated yesterday for lethargy-today (sic) having episodes of vomiting. Reevaluation."" Under review of symptoms, the CNP recorded, ""The patient complained of lethargy but denied fever and chills"", ""patient denied difficulty swallowing, sore throat and headache"", ""patient denied sOB (sic) and cough"", and ""patient complained of nausea, vomiting (small amount x 3) and decreased appetite but denied diarrhea and constipation"". Under physical examination, the CNP recorded the resident's pharynx was clear, her respiratory system was ""CTA (clear to auscultation) Bilaterally (diminished), left lower lung field: (sic) diminished, right lower lung field: diminished and rales (faint)."" The CNP recorded the resident's vital signs as: ""blood pressure at Left Arm while Sitting is ,[DATE] (sic) mm/Hg 121 bpm regular 97.6F 139 pounds clothed."" Under prescriptions, the CNP recorded: ""[MEDICATION NAME] 10 mg Rectal Suppository, 1 Unit Dose and RTL. [MEDICATION NAME] 40 mg Cap, Delayed Release, 1 Capsule(s), PO and QD. [MEDICATION NAME] 12.5 mg Rectal Suppository, 1 Unit Dose, RTL, Q6 PRN, 5 days start on [DATE] and end on [DATE]. [MEDICATION NAME] 1 gram Solution for Injection, 1, InVt, QD, 7 days, start on [DATE] and end on [DATE]."" Under services ordered, the CNP recorded a chest x-ray. At the end of the progress note was written: ""Resident has hx. of Reflux but currentlyl (sic) is not on PPI. Will order [MEDICATION NAME]. O2 2 liters nc and observe closely. Will start IV fluids @ 50 cc/hr until obtain chest x ray and stat dose [MEDICATION NAME]."" - The result of the sedimentation rate study was called to the facility at 9:55 a.m. on [DATE], with no abnormal finding. The results of the CBC and BMP were sent to the facility at 12:23:52 (12:23 p.m.) on [DATE] (according to the date / time stamp recorded at the top of each page of the report), with abnormal results including: glucose - 126 (normal range 83 - 110); BUN - 35 (normal range 6 - 20); white blood cells - 14.5 (normal range 4.8 - 10.8); red blood cells - 3.65 (normal range 4.2 - 5.4); hemoglobin - 10.7 (normal range 12.0 - 16.0); and hematocrit - 34.2 (normal range 36 - 48). - A second CNP progress note dated [DATE] was identified as having been an amendment to the earlier progress note at 1:57 p.m. on [DATE]. This amendment, which was electronically signed by the CNP at 10:44 a.m. on [DATE], contained the exact same information as found on the earlier note for [DATE] under the headings chief complaint, review of symptoms, physical examination, diagnoses, prescriptions, services performed, and services ordered. At the end of the progress note was written: ""Resident has hx. (history) of Reflux but currentlyl (sic) is not on PPI (protein pump inhibitor). Will order [MEDICATION NAME]. O2 2 liters nc (via nasal cannula) and observe closely. Will start IV fluids @ 50 cc/hr until obtain chest xray and stat dose [MEDICATION NAME]. REceived (sic) labs - WBC 14.5 BMP BUN (blood urea nitrogen) 35 otherwise WNL (within normal limits). Stronger evidence of pneumonia. Have consulted Resp. Tx. (respiratory therapy) for evaluation and treatment."" - The CNP progress note timed at 11:59 a.m. on [DATE] was the only evidence to reflect Resident #119 was seen / assessed by the CNP that day. - Two (2) sheets of orders handwritten by the CNP were found for [DATE]; none of the orders contained a time to indicate at what time on this date they were actually written, and neither sheet contained notations to indicate what time the desk nurse noted having received the orders. The first sheet of orders contained two (2) sets of entries as follows: ""[MEDICATION NAME] 10 mg suppository now. [MEDICATION NAME] 40 mg po reflux. [MEDICATION NAME] 12.5 mg suppository Q 8 (symbol for hours) PRN nausea x 5 days vomiting."" and ""IV: ,[DATE] NSS (sterile normal saline) i (1) liter @ 50 cc/hr. [MEDICATION NAME] i Gm IV now & daily x 7 days. O2 3 Liters n/c (via nasal cannula)."" The second sheet of orders contained one (1) set of entries as follows: ""IV: 0.9 NSS i liter @ 50 cc/hr - (arrow pointing up) HR (heart rate). [MEDICATION NAME] 1 Gm IV STAT & QD (daily) x 7 days - (arrow pointing down) O2 sat (oxygen saturation). O2 3 L (liters) per N/C. [MEDICATION NAME] 12.5 mg suppository Q 6 (symbol of hours) PRN (as needed) nausea x 5 days. [MEDICATION NAME] 40 mg i daily po (by mouth) - reflux. [MEDICATION NAME] 10 mg suppository today. Resp Tx eval & treat - (arrow pointing down) O2 sat. Chest x-ray STAT - (arrow pointing down) O2."" - An interview was conducted on [DATE] at 12:45 p.m. with the facility's CNP (Employee #123). The CNP reported she had been at the facility all day on [DATE] and had provided care for Resident #119. The CNP stated she initially wrote orders thinking the resident may have had an obstruction, but after receiving further assessments from the nurses and receiving the results of labs that had previously been ordered, it became evident to her the resident probably had pneumonia. The CNP further stated it was her role to provide all the care at the facility, so that she could to prevent trips by residents to the hospital. She also stated the nurses were ""too accustomed to picking up the phone and calling EMS"". - An interview was conducted on [DATE] at 12:15 p.m. with Employee #19, who was the desk nurse on [DATE]. Employee #19 stated she received a first set of orders from the CNP at 1:00 p.m. on [DATE] (for the [MEDICATION NAME], and [MEDICATION NAME]). Employee #19 said she later received a second set of orders from the CNP (for the [MEDICATION NAME], IV fluids, supplemental oxygen, and chest x-ray). According to Employee #19, when she questioned the CNP about what to do with the first set of orders, the CNP stated the resident had possible pneumonia and the most important thing at this point was to start the IV fluids and get the chest x-ray. - Further review of the resident's closed record, including nursing notes and medication administration records, found no evidence the stat dose of [MEDICATION NAME] had been given or that Resident #119 received a single dose of [MEDICATION NAME] to treat her nausea / vomiting prior to her transfer to the hospital at 7:22 p.m. on [DATE]. -- 9. In an interview conducted on [DATE] at 4:15 p.m., Employee #79 (who was the LPN assigned to care for Resident #119 from 7:00 a.m. to 7:00 p.m. on [DATE]) reported she was first made aware of the resident vomiting when a ,[DATE] shift nursing assistant came to her and informed her of the vomiting and inquired about the resident's code status. Employee #79 reported she ""went immediately to the resident's room, recognized the resident's condition, and went immediately to the phone to call EMS."" This nurse also stated, during an earlier interview conducted on [DATE] at 12:05 p.m., she believed the res",2014-03-01
11412,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-11-11,328,D,,,50T311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review and staff interview, the facility failed to ensure one (1) of six (6) sampled residents, whose closed record was reviewed, received proper care and treatment for [REDACTED]. Resident #119 was [AGE] years old female who was admitted to the facility from the hospital following a surgical procedure for a [MEDICAL CONDITION]. During a prolonged hospital stay, she was also treated for [REDACTED]. Review of Resident #119's medication administration records (MARs) revealed she was frequently noted to refuse her inhalation treatments; these refusals were not communicated to her attending physician. Facility policy required licensed nursing staff to collect and record physical assessment data regarding the resident's respiratory status before and after the administration of each inhalation, as well as the resident's response to each treatment after it was completed. Review of her nursing notes and MARs found no evidence this physical assessment data was being collected and recorded in accordance with facility policy. The resident subsequently exhibited an acute change in condition, which the certified nurse practitioner ultimately considered was attributable to possible pneumonia. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 1. Review of Resident #119's closed medical record revealed this [AGE] year old female was admitted to the nursing facility on 09/30/10 following a prolonged hospital stay beginning on 09/09/10 for a surgical repair of a [MEDICAL CONDITION], during which she received treatment for [REDACTED]. Review, on 11/10/10, of Resident #119's October 2010 MAR indicated [REDACTED]. - 2. According to documentation on her October 2010 MAR, between 10/01/10 and 10/11/10, Resident #119 did not receive twenty-five (25) of sixty-six (66) scheduled inhalation treatments. Of these twenty-five (25) missed doses, coding on the MAR indicated [REDACTED]. Medical record found no documentation reflecting either the physician or the physician extender had been notified of the resident refusing these treatments. This notification would have provided the physician an opportunity to change / modify treatment for [REDACTED].) - 3. Review of the resident's care plan, which had been initiated on 10/07/10, revealed the following problem statement: ""Short of breath / difficulty breathing related to: [MEDICAL CONDITION]."" Interventions to address this problem included: ""Administer medication as ordered. ... Notify physician of increased complaints of difficulty in breathing. Obtain oxygen saturation levels. Obtain vital signs. Provide nebulizer treatments as ordered."" - Review of documentation recorded in the resident's nursing notes and on the September and October MARs found no evidence that any physical assessment data regarding the resident's respiratory status had been collected and recorded either prior to and after each nebulizer treatment. - Review of the facility's policy ""Aerosolized Medication (Neb Med)"" (with a revision date of May 2002) found the following under Item #4 under guidelines: ""h. Assess the Resident ""(1) Note the resident's skin color and temperature, skin characteristics (warm and dry vs. cold and clammy; elastic vs. [MEDICAL CONDITION]), pattern and effort of breathing, ability to take a deep breath and cough and quality of breath sounds. If medication is being given for wheezing, note quality and intensity so as to be prepared to document post-[MEDICATION NAME][MEDICATION NAME] effects. ""(2) Check respiratory rate prior to treatment."" According to the policy, after the nebulizer treatment ceases, the following steps were to be completed: ""n. Assess the resident to determine therapeutic outcome. ... ""r. Document medication, [MEDICATION NAME], dose, pulse and breath sounds before and after the treatment, O2 (oxygen) liter flow, cough, color and consistency of sputum, resident (sic) subjective response and any adverse reactions and action taken."" - During an interview on 11/10/10 at 3:30 p.m., the director of nursing (DON - Employee #81) revealed that any documentation related to the implementation of this policy would be recorded in the resident's nursing notes. - During an interview on 11/10/10 at 4:15 p.m., the licensed practical nurse (LPN - Employee #79), who initialed Resident #119's MAR indicated [REDACTED]#119's respiratory status before and after administering these nebulizer treatments. (See also citation at F281.) - 4. A CNP progress note dated 10/13/10 (and electronically signed at 2:46 p.m. the same day) identified that Resident #119 presented with lethargy and ""the symptom started 7 days ago."" Under review of symptoms, the CNP recorded, ""The patient complained of malaise and lethargy but denied fever and chills"" and she ""denied cough"". Under physical examination, the CNP recorded Resident #119's pharynx was clear and her lungs were clear to auscultation bilaterally. Under services ordered, the CNP recorded a CBC, BMP, and RBC sed rate. At the end of the progress note was written: ""Resident appears to be stable. Will obtain labs and reevaluate. If normal labs, will consider adjusting medication."" - A CNP progress note dated 10/14/10 (and electronically signed electronically at 11:59 a.m. the same day) revealed, under chief complaint, ""(Resident #119) presented with vomiting. It is described as acute. The symptom is sudden in onset. The symptom started 4 hours ago. The complaint is mild. Episodes occur in the morning. ... In addition, she presented with shortness of breath. It is described as stable. The symptom is gradual in onset. ... Patient denies apnea, cough, [MEDICAL CONDITION] and sputum production. ... Evaluated yesterday for lethargy-today (sic) having episodes of vomiting. Reevaluation."" Under review of symptoms, the CNP recorded, ""The patient complained of lethargy but denied fever and chills"", ""patient denied difficulty swallowing, sore throat and headache"", ""patient denied sOB (sic) and cough"", and ""patient complained of nausea, vomiting (small amount x 3) and decreased appetite but denied diarrhea and constipation"". Under physical examination, the CNP recorded the resident's pharynx was clear, her respiratory system was ""CTA (clear to auscultation) Bilaterally (diminished), left lower lung field: (sic) diminished, right lower lung field: diminished and rales (faint)."" The CNP recorded the resident's vital signs as: ""blood pressure at Left Arm while Sitting is 135/738 (sic) mm/Hg 121 bpm regular 97.6F 139 pounds clothed."" Under prescriptions, the CNP recorded: ""[MEDICATION NAME] 10 mg Rectal Suppository, 1 Unit Dose and RTL. [MEDICATION NAME] 40 mg Cap, Delayed Release, 1 Capsule(s), PO and QD. [MEDICATION NAME] 12.5 mg Rectal Suppository, 1 Unit Dose, RTL, Q6 PRN, 5 days start on October 14, 2010 and end on October 18, 2010. [MEDICATION NAME] 1 gram Solution for Injection, 1, InVt, QD, 7 days, start on October 14, 2010 and end on October 20, 2010."" Under services ordered, the CNP recorded a chest x-ray. At the end of the progress note was written: ""Resident has hx. of Reflux but currentlyl (sic) is not on PPI. Will order [MEDICATION NAME]. O2 2 liters nc and observe closely. Will start IV fluids @ 50 cc/hr until obtain chest x ray and stat dose [MEDICATION NAME]."" - The result of the sedimentation rate study was called to the facility at 9:55 a.m. on 10/14/10, with no abnormal finding. The results of the CBC and BMP were sent to the facility at 12:23:52 (12:23 p.m.) on 10/14/10 (according to the date / time stamp recorded at the top of each page of the report), with abnormal results including: glucose - 126 (normal range 83 - 110); BUN - 35 (normal range 6 - 20); white blood cells - 14.5 (normal range 4.8 - 10.8); red blood cells - 3.65 (normal range 4.2 - 5.4); hemoglobin - 10.7 (normal range 12.0 - 16.0); and hematocrit - 34.2 (normal range 36 - 48). - A second CNP progress note dated 10/14/10 was identified as having been an amendment to the earlier progress note at 1:57 p.m. on 10/14/10. This amendment, which was electronically signed by the CNP at 10:44 a.m. on 10/15/10, contained the exact same information as found on the earlier note for 10/14/10 under the headings chief complaint, review of symptoms, physical examination, diagnoses, prescriptions, services performed, and services ordered. At the end of the progress note was written: ""Resident has hx. (history) of Reflux but currentlyl (sic) is not on PPI (protein pump inhibitor). Will order [MEDICATION NAME]. O2 2 liters nc (via nasal cannula) and observe closely. Will start IV fluids @ 50 cc/hr until obtain chest xray and stat dose [MEDICATION NAME]. REceived (sic) labs - WBC 14.5 BMP BUN (blood urea nitrogen) 35 otherwise WNL (within normal limits). Stronger evidence of pneumonia. Have consulted Resp. Tx. (respiratory therapy) for evaluation and treatment."" .",2014-03-01
11413,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-11-11,514,D,,,50T311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff 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 maintain, in accordance with accepted standards of professional practice, the medical record of one (1) of six (6) sampled residents whose closed record was reviewed. Review of the closed record for Resident #119 revealed licensed nursing staff failed to document every change in her condition until her condition was stabilized or the situation was otherwise resolved, in accordance with professional standards of practice. Late entries in Resident #119's nursing notes were not recorded as soon as possible, with one (1) nursing note containing six (6) separate late entries having been recorded seven (7) days after the resident expired, even though the author of that note was working in the facility two (2) days after the resident transferred to the hospital. Additionally, a review of hospital discharge orders from the physician prior to Resident #119's admission on [DATE] found an order for [REDACTED]. The resident's [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This discrepancy in frequency of administration of the inhalation treatments was not identified previously by the facility. These practices did not allow for accurate and complete clinical information about this resident's change in condition and treatments. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 1. Review of Resident #119's closed record revealed this [AGE] year old female was admitted to the facility on [DATE] after a prolonged hospital stay. Review of Resident #119's nursing notes found a contemporaneous entry, dated [DATE] at 3:00 a.m., stating, ""Skilled services continue. (Symbol for 'no') S/S (signs / symptoms) of distress or discomfort @ this time. Meds taken /s (without) difficulty. In bed /c (with) eyes closed. Call light in reach."" The next consecutive entry, dated [DATE] at 5:10 p.m., stated, ""N/O (new order) noted. CBC (complete blood count), BMP (basic metabolic panel), sed (sedimentation) rate d/t (due to) lethargy. Family aware."" Between 3:00 a.m. and 5:10 p.m. on [DATE], there was no documentation in the nursing notes of any observations and/or nursing assessments of Resident #119's health status completed by the facility's licensed nursing staff. The next consecutive entry in the nursing notes, dated [DATE] at 5:00 a.m., stated, ""Resident vomited x 3 this shift. Will monitor."" This is the first mention in the resident's record of her having vomited. There was no description of the characteristics of the emesis (e.g., color, quantity, consistency, etc.), and no vital signs (e.g., temperature, blood pressure, heart rate, respirations) were recorded either in the nursing notes or a separate vital signs flow sheet. There was no documentation to indicate nursing staff notified the resident's responsible party, attending physician, or the CNP employed by the facility, of this change in the resident's condition. There was also no discussion of whether the resident remained lethargic, as had been noted at 3:00 a.m. on [DATE] and for which the CNP had previously ordered lab studies. The next consecutive entry in the nursing notes, dated [DATE], at 10:00 a.m., stated, ""Weekly care team IDT (interdisciplinary team) review: Tylenol Q 8 ATC x 7 days. F/U (follow-up appointment) Dr. (name) on [DATE]. [MEDICATION NAME] & [MEDICATION NAME] for dementia. OT (occupational therapy), PT (physical therapy) as ordered. ST (speech therapy) as ordered. [MEDICATION NAME] to groin & breasts. Dry drsg (dressing) to Lt (left) knee."" This interdisciplinary note was recorded by an RN, but it did not contain any mention of acute changes in condition exhibited by the resident in the previous twenty-four (24) hour period (e.g., lethargy or vomiting). The next consecutive entry in the nursing notes, dated 1:05 p.m. on [DATE], stated, ""N.O. (new order) Bilateral heels off bed /w (with) pillows @ (at) all x's (times) for prevention. N.O. Sure Prep to bilateral heels 2x's QD (twice daily) on NS (night shift), DS (day shift) for prevention."" This entry was not signed by its author. The next consecutive entry in the nursing notes, dated [DATE] at 4:-0 p.m. (the exact time of the entry was illegible), stated, ""N/O for chest x-ray d/t cough & congestion, Attempts x 3 to call MPOA (medical power of attorney) /s success. This entry was recorded by Employee #19, an LPN. There was no mention of the resident's level of consciousness with respect to whether she remained lethargic, there was no mention of whether she had continued to vomit, and even though this was the first mention of the resident having exhibited any cough or congestion, there was no quantitative or qualitative description of her respiratory status (e.g., rate of respirations, blood oxygen saturation level, presence or absence of adventitious sounds in her lung fields, difficulty or ease of breathing, etc.) or her vital signs. The next consecutive entry in the nursing notes, made by LPN Employee #19 and dated [DATE] at 5:25 p.m., stated, ""QMI (name of mobile imaging company) on site; CXR (chest x-ray) done."" The next consecutive entry in the nursing notes, made by Employee #19 and dated [DATE] at 7:00 p.m., stated, ""MPOA notified of decline; wish (sic) to send to TMH (area hospital)."" The next consecutive entry in the nursing notes, made by Employee #19 and dated [DATE] at 7:22 p.m., stated, ""KCA (local ambulance service) on site to transport to KCA (sic) /c (with) accompanied (sic) on ii (2) attendants."" The next consecutive entry in the nursing notes, dated [DATE] at 8:00 a.m., stated, ""Expired @ TMH ER (emergency room ) @ 9:50 p.m. [DATE]."" - According to the AHIMA LTC documentation guidelines: ""5.2.15. Condition Changes ""Every change in a resident's condition or significant resident care issues must be noted and charted until the resident's condition is stabilized or the situation is otherwise resolved. Documentation that provides evidence of follow-through is critical."" The licensed nursing staff failed to note and chart every change condition or significant resident care issues involving Resident #119's health status in accordance with professional standards of practice. -- 2. Review of the closed medical record for Resident #119, who was transferred to the hospital on the evening of [DATE] and subsequently expired, found a nursing note, dated [DATE] at 3:27 p.m., which contained six (6) separate late entries describing events said to have occurred one (1) week earlier between 1:00 p.m. and 5:00 p.m. on [DATE]. - According to the ""as-worked"" nursing schedule provided at 3:30 p.m. on [DATE] by the director of nursing (DON - Employee #81), the author of the late entries recorded on [DATE] (a licensed practical nurse (LPN - Employee #19)) worked from 7:00 a.m. to 7:30 p.m. on [DATE]. During the 7:00 a.m. to 7:30 p.m. shift on [DATE], Employee #19 recorded entries at 4:-0 (exact time not legible), 5:25 p.m., 7:00 p.m., and 7:22 p.m.; Employee #19 worked in the facility again from 7:00 a.m. to 7:30 p.m. on [DATE], and from 7:00 a.m. to 7:30 p.m. on [DATE] and would have been available to record these late entries more timely than she did. - According to the AHIMA LTC documentation guidelines: ""5.3.2.1. 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. ... ""When using late entries 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."" The late entries recorded by Employee #19 were not entered into Resident #119's record as soon as possible (which would have been during the 7:00 a.m. to 7:30 p.m. shift on [DATE]. Instead, they were recorded seven (7) days after the resident expired. This significant delay in recording the late entries calls into question the reliability of their contents. -- 3. Review of Resident #119's closed medical record revealed this [AGE] year old female was admitted to the nursing facility on [DATE] following a prolonged hospital stay beginning on [DATE] during which she received treatment for acute [MEDICAL CONDITION] (ARF). Her discharge orders from the hospital included the administration of [MEDICATION NAME] inhalation treatments every four (4) hours. - Review of the [DATE] MAR found, for her only day present in the facility in September ([DATE]), she had an order to receive [MEDICATION NAME] inhalation treatments every six (6) hours (at regular intervals four (4) times a day). Review of the [DATE] MAR indicated [REDACTED]. - In an interview at 3:30 p.m. on [DATE], the DON reported the resident was to have received the inhalation treatments every four (4) hours and the physician orders [REDACTED]. - Review of a progress note dictated by the certified nurse practitioner (CNP), dated [DATE] and electronically signed at 2:39 p.m., found an entry stating to continue to nebulizer treatment for two (2) weeks and re-evaluate. Review of the physician orders [REDACTED]."" Further review of physician orders [REDACTED]. Based on the information available in the resident's closed record, it is unclear when one (1) or more transcription errors may have occurred - when the CNP recorded the handwritten order to continue the [MEDICATION NAME] treatments on [DATE] (at a frequency different from what was specified in the resident's hospital discharge order), or when the order was carried over from the [DATE] MAR indicated [REDACTED]",2014-03-01
11414,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2010-11-18,311,D,,,0ZJV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, and staff interview, the facility failed to provide treatment and services to maintain or improve the range of motion in both hands, for one (1) of eight (8) residents who had contractures of both hands and a physician's orders [REDACTED]. Resident identifier: #41. Facility census: 117. Findings include: a) Resident #41 Medical record review, on 11/16/10, revealed this resident had a physician's orders [REDACTED]. The order, dated 09/28/10, was for the protectors to be applied for eight (8) hours daily beginning at 9:00 a.m. each morning. Observations, at 2:00 p.m. on 11/16/10, at 9:30 a.m. on 11/17/10, at 1:00 p.m. on 11/17/10, and at 3:00 p.m. on 11/17/10, revealed neither hand had a palm protector in place. At 3:30 p.m. on 11/17/10, this information was brought to the attention of a licensed practical nurse (LPN - Employee #7), who confirmed the order and confirmed the palm protectors were not being used.",2014-03-01
11415,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2010-11-17,309,G,,,TRO311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and family interview, the facility failed to provide care and services to maintain the highest practicable physical well-being in accordance with the comprehensive plan of care for two (2) of eighteen (18) Stage II sample residents. Resident #153 complained to her family of a sore mouth, tongue, and throat, which the resident's legal representative conveyed to the facility. The facility's licensed nursing staff failed to collect and record physical assessment data related to the condition of the resident's entire oral cavity and related to the attending physician only the presence of a slightly inflamed tongue, for which the physician ordered a medicated [MEDICATION NAME]. The resident's legal representative ultimately made an appointment for the resident to be evaluated and treated by a second physician outside the facility, who diagnosed glossitis, mouth ulcers, and possible candidiasis and ordered five (5) medications for treatment of [REDACTED]. A nurse failed to ensure Resident #73 received all medications ordered by the physician during a medication pass on the morning of 11/10/10. Resident identifiers: #153 and #73. Facility census: 98. Findings include: a) Resident #153 An interview with the Resident #153's daughter, on 11/11/10 at 8:50 a.m., revealed the resident had been in pain from sores in her mouth and the resident's tongue was irritated and swollen. The resident had told the her the inside of her mouth had sores, her tongue was very irritated, and that her throat was also sore. According to the daughter, her brother visited Resident #153 and reported back to her that he had observed sores in the mouth and that her tongue was red. The daughter further stated she called the facility and asked for the physician to look at her mother's mouth. According to the daughter, the facility's physician did not look at her mother's mouth, so she called her mother's previous attending physician (who was no longer affiliated with the facility) and made an appointment to have her evaluated. - Record review revealed a nursing note, dated 04/28/10 at 5:30 p.m., which stated, ""... Resident C/O (complained of) sore tongue (sic) slightly red / inflamed. (Name of attending physician) notified (sic) new order [MEDICATION NAME] 10 mg x 2 weeks - resident notified."" On 04/29/10 at 1:00 a.m., a nurse wrote, ""... [MEDICATION NAME] cont(inued) for mouth soreness. No complaints at this time."" On 04/29/10 at 7:40 a.m., a nurse wrote, ""... [MEDICATION NAME] to begin this AM (morning) for sore mouth, tongue slightly red and irritated. ..."" On 04/29/10 at 4:00 p.m., a nurse wrote, ""... [MEDICATION NAME] cont /s (without) adverse effects noted r/t (related to) sore touth (sic), tongue - slightly red / irritated - denies any further C/O (complaints). ..."" On 04/30/10 at 8:00 a.m., a nurse wrote, ""... [MEDICATION NAME] cont /c (with) no adverse effects noted for sore mouth, tongue slightly red, irritated. Denies any C/O this AM. ..."" On 04/30/10 at 11:30 a.m., a nurse wrote, ""Dtr (daughter) made appt (appointment) today /c (name of outside physician) at 1:30 p - follow-up (sic). Facility to take."" On 04/30/10 at 3:00 p.m., a nurse wrote, ""Returned back from (name of outside physician). Dx (diagnosis): glossitis, mouth ulcers, possible candidias (sic). New orders OK per (name of facility's physician): (1) [MEDICATION NAME] xylocane (sic) 1 tablespoon swish, gargle, and swallow QID (four times a day) x 10 days. (2) [MEDICATION NAME] 150 mg qday (sic) (every day) x 3 days. (3) 2 cc B12 IM (intramuscular injection) in AM. (4) 80 mg [MEDICATION NAME] IM x 1. (5) [MEDICATION NAME] oral susp(ension) 1 tsp QID PO (by mouth) swish, gargle, and swallow x 10 days. Dtr notified. Cont to monitor."" This entry was followed by an addendum, dated 04/30/10, noting the discontinuation of the [MEDICATION NAME]. - The nursing entries from 04/28/10 until 04/30/10 only addressed the resident's irritated tongue and did not contain evidence of an assessment of the resident's oral cavity as a whole; there was no mention of the presence of mouth ulcers which had been identified by the outside physician on the afternoon of 04/30/10. - In an interview on 11/16/10 at 8:45 a.m., the director of nursing (DON - Employee #88) reported the nurses had assessed the resident's mouth and only found that the resident had an irritated tongue. A nurse called the facility's physician and told him about the irritated tongue, and he ordered [MEDICATION NAME]. The DON provided, as evidence of assessment of the resident's oral cavity, a nursing assessment form (which include an oral / nutritional assessment) dated 02/27/10. However, this nursing assessment was completed two (2) month before the resident was diagnosed by the outside physician as having a glossitis, mouth ulcers, and possible candidiasis, for which he ordered treatment with five (5) medications. The DON further stated the facility's physician was in and visited the resident on 04/26/10, and there was no evidence the resident had complained about a sore mouth at that time. - A review of the physician's progress notes found an entry, dated 04/26/10, which did not indicate the resident had complained of a sore mouth. This physician visit, however, occurred two (2) days prior to the resident's first complaint of a sore mouth on 04/28/10. - A review of the monthly summary completed, by a licensed nurse on 04/05/10, revealed a section titled ""16. Oral Hygiene"". Within this section was ""Condition of Mouth"" followed by a space where a description of findings could be recorded; this space was left blank. - Review of nursing notes entered in the medical record after the resident returned from her outpatient physician visit on the afternoon of 04/30/10 with orders to treat found references to the resident's complaints of mouth pain or discomfort in entries made at 4:00 p.m. on 05/01/10, at 6:20 a.m. on 05/02/10, at 9:50 a.m. on 05/02/10, and at 4:00 p.m. on 05/02/10. However, there were no entries describing the physical condition of the resident's oral cavity until 10:00 p.m. on 05/03/10, when a nurse wrote: ""... Cont to have observable mouth ulcerations /c C/O discomfort..."" - Resident #153's daughter, after hearing complaints of oral pain and soreness from the resident and after hearing a report by her brother of the presence of sores in her mother's mouth, reported having asked facility staff to have the attending physician evaluate her. The facility failed to provide a full assessment, either by a registered nurse or the physician, of the resident's oral cavity after the resident complained of pain and soreness to her mouth. The resident's daughter was required to intervene and schedule an appointment with an outside physician in order to obtain appropriate treatment for [REDACTED]. -- b) Resident #73 During the observation of the passing of medications at 9:00 a.m. on 11/10/10, the licensed practical nurse (LPN - Employee #13) failed to administer [MEDICATION NAME] 25 mg which was ordered to be given at that time to Resident #73. The nurse surveyor compared the list of medications verbally told to her by the LPN during the medication pass (and observed being given to the resident) with the physician's orders [REDACTED]. Employee #13 continued on with her medication pass to the remaining residents on the B hall. During an interview with Employee #13 at 9:50 a.m. on 11/10/10, after she had completed the pass, she acknowledged she had not administered the [MEDICATION NAME]. She reviewed the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A comparison of the medications in the medication cart labeled for use by Resident #73 with the resident's MAR indicated [REDACTED] .",2014-03-01
11416,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2010-11-17,315,G,,,TRO311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and family interview, the facility failed to provide care and services for one (1) resident of five (5) sampled residents with an indwelling Foley urinary catheter who was exhibiting signs and symptoms of a urinary tract infection [MEDICAL CONDITION] and did not receive timely medical intervention. The resident was transferred to the hospital after becoming lethargic on [DATE], four (4) days after she was first symptomatic for a UTI on [DATE] (as evidenced by an elevated temperature and a finding of ""very cloudy and dark"" urine). The resident subsequently died at the hospital [MEDICAL CONDITION] on [DATE]. Resident identifier: #153. Facility census: 98. Findings include: a) Resident #153 Closed record review revealed Resident #153 was a [AGE] year old female who was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Resident #153's comprehensive admission assessment with an assessment reference date (ARD) of [DATE], she had short-term memory problems but no long-term memory problems, she exhibited modified independence with her cognitive skills for daily decision making, she required the extensive physical assistance of two (2) or more persons with bed mobility and transfers, and she was totally dependent on two (2) or more persons with toilet use. She was also incontinent of bowel elimination, continent of bladder elimination with the presence of an indwelling Foley urinary catheter, and had been diagnosed with [REDACTED]. According to her comprehensive annual assessment with an ARD of [DATE], Resident #153's cognitive status remained the same, she required the extensive physical assistance of one (1) person with bed mobility, she was totally dependent on two (2) or more persons for transfers, and she required the extensive physical assistance of two (2) or more persons with toilet use. She was also now continent of bowel elimination and bladder elimination with the presence of an indwelling urinary catheter, and she had NOT been diagnosed with [REDACTED]. -- According to her care plan dated [DATE] through [DATE], the interdisciplinary team identified the following problem: ""Risk for infection R/T (related to) indwelling foley (sic) cath (sic) and hx (history) of uti (sic)."" The goal associated with this problem statement was: ""Resident will exhibit no s/sx (signs / symptoms) of UTI thru next review aeb (as evidenced by) afebrile, no change in sedimentation of urine."" The interventions intended to assistant the resident in achieving this goal included: ""#16F foley (sic) with 30cc balloon per orders, Change Q (every) 4 weeks and prn (as needed). change (sic) urinary drainage bag Q 4 weeks and prn. Foley cath care Q shift. Provide incontinence cares (sic) frequently as able ensuring proper peri care due to increased risk of ecoli (sic) infection. Encourage and assist with fluids with and between meals for preventative measures. Monitor for s/sx of UTI such as hematuria (blood in urine), dysuria (painful urination), pyuria (pus in urine), abdominal pain, temp (sic), increasd (sic) confusion, etc. Notify MD as needed. hx (sic) of vre ([MEDICATION NAME]-resistant [MEDICATION NAME]). Monitor for s/s of uti (sic) during periods of increased blood sugars. Notify md (sic) of findings."" -- A nursing note, dated [DATE] at 12:30 a.m., revealed, ""Temp (temperature) 100.2 (symbol for 'oral') ... Urine very cloudy and dark. New order (sic) UA (urinalysis) & C&S (culture and sensitivity) this AM (morning) ...."" A nursing note, dated [DATE] at 11:15 p.m., stated, ""Labs returned. Abnormal UA - pH 9.0, Protein 75, Blood 250, Leukocyte Est 500 preliminary (sic) awaiting final."" (The normal ranges for these labs are: pH = 4XXX,[DATE].0, Protein = negative (0), Blood = negative (0), and Leukocyte Est = negative (0).) The next consecutive entry in the nursing notes, dated [DATE] at 12:20 a.m., stated, ""Temp 97.6 (Ax) (axillary). Foley catheter draining cloudy dark yellow."" The next consecutive entry, dated [DATE] at 11:00 a.m., stated, "" ... yells / moans @ (at) times (sic) complaints generally nonspecific and cease /c (with) conversation. T (temperature) 99.0 (symbol for 'oral') awaiting final C&S of UA. foley (sic) cath patent (sic) draining tea colored urine. denies (sic) abd(ominal) pain upon palpation. C/O (complains of) bladder feeling full (sic) abd small & soft. ... fluids (sic) encouraged by staff as well as ice chips ... will continue to monitor."" The next consecutive entry, dated [DATE] at 4:00 p.m., stated, ""Temp 98.6 (Ax). ... Yells / moans out occas (occasionally) /c C/O mouth pain. ... ice chips & fluids encouraged. foley (sic) cath patent draining dark tea colored urine - slightly blood tinged. Awaiting C&S of UA. ..."" The next three (3) consecutive entries in the nursing notes (dated [DATE] at 6:20 a.m., [DATE] at 9:50 a.m., and [DATE] at 4:00 p.m.) contained no mention of the status or characteristics of the resident's urinary output. The next entry, dated [DATE] at 2:10 a.m., stated, "" ... Indwelling foley (sic) drng (draining) small - mod amts of dk sl amber urine. ..."" The next consecutive entry in the nursing notes, dated [DATE] at 10:00 a.m., stated, ""Temp 99.6 (Ax). Lethargic. C/O not feeling well (sic) not wanting to be bothered."" An addendum following this entry stated, ""10 am. Received napoxen (sic) ([MEDICATION NAME] - a non-steroidal anti-[MEDICAL CONDITION] drug) @ 7:45 a.m. Will cont to monitor for S/Sx fever; infection."" The next consecutive entry, dated [DATE] at 11:00 a.m., stated, ""Up to BSC (bedside commode) (sic) became very weak, pale. Put back to bed. BP (blood pressure) ,[DATE]. P (pulse) 84. Skin cool (sic) clammy. After stimulation BP ,[DATE] P 82. Had expelled hard BM (bowel movement) prior to episode."" The next consecutive entry, dated [DATE] at 11:30 a.m., stated, ""Yelling (sic) insisting to be back up on BSC. ..."" This was followed by an entry by the same author with the same date and time, noting that a dose of [MEDICATION NAME] was withheld related to a possible adverse effect. The next consecutive entry, dated [DATE] at 10:00 p.m., stated, "" ... also C/O feeling very weak - orders rec (received) for lab wk (work) in AM (morning). Res (resident) made aware."" The next consecutive entry, dated [DATE] at 4:00 a.m., stated, ""Resting quietly in bed - awakens easily (sic) appears sl (slightly) listless. ... Ate 0% of meals [DATE] /c only (approx) 300 ml of fluids /c meals ..."" The next consecutive entry, dated [DATE] at 5:00 a.m., noted the arrival of the vendor laboratory service to collect specimens for blood work. The next consecutive entry, dated [DATE] at 10:00 a.m., stated, ""Lethargic. BS (blood sugar) elevated. BP low. Consulted Dr. (name of attending physician) /c exam. New order. Novalog ,[DATE] 10 units bid (twice daily). IV (intravenous fluids) 0.45% NaCl @ 100 cc/hr x 2 hours then 80 cc/hr. Transfer to (name of hospital) ER for eval."" The next four (4) entries in the nursing notes recorded the successful insertion of the IV, notification of the resident's change in condition and transfer to the resident's legal representative, transfer of the resident to the hospital, and mailing of the notice of transfer and bedhold policy to the resident's legal representative. -- The above nursing notes recorded evidence of the resident exhibiting signs and symptoms of a UTI beginning on [DATE] (e.g., dark, cloudy urine; blood in urine; low grade temperature; lethargy). These signs and symptoms continued without treatment or physician intervention from [DATE] until [DATE], when the resident was transferred to the hospital. -- Review of a lab specimen inquiry dated [DATE] with a run time of 1146 (11:46 a.m.) revealed the following abnormal results of the blood work collected in the early morning hours of [DATE]: - Glucose - 354 (normal range ,[DATE]) - Blood urea nitrogen (BUN) - 194 (normal range ,[DATE]) Below this lab value on the report was typed, ""Tried to notify Sunbrige (sic) of results - could not get pick-up on floor. Notified (name) (front desk) that I would be faxing results to floor. ..."" - Creatinine - 5.1 (normal range 0XXX,[DATE].3) - B/C (BUN / Creatinine) Ratio - 38 (normal range ,[DATE]) - Potassium - 5.1 (normal range 3XXX,[DATE].5) -- Lab results after Resident #153 arrived at the hospital revealed the following: - Urine specimen collected on [DATE] (with results dated [DATE]) - the appearance was noted to be ""turbid (cloudy) specimen red"" with ""large"" amount of blood, equal to or greater than 300 mg/dl of protein in the urine, with a quantity of red blood cells in the urine ""too numerous to count"" and ""loaded"" with bacteria. - Blood specimen collected on [DATE] (with results dated [DATE]) - cultured positive for [DIAGNOSES REDACTED] pneumoniae and Streptococcus mitis group. The resident was septic and subsequently expired at the hospital on [DATE]. -- An interview with the director of nursing (DON - Employee #88), on [DATE] at 8:45 a.m., revealed the resident's attending physician would always wait until the final lab report was received to determine what antibiotic to order. She further stated the physician would treat if a resident were symptomatic, but according to the DON, Resident #153 only had an elevated temperature on [DATE] and was not symptomatic of a UTI. -- Resident #153 was exhibiting signs and symptoms of a UTI beginning on [DATE] and continuing to [DATE], when the resident was transferred to the hospital. There was no evidence to reflect staff notified the attending physician of the resident's dark, cloudy urine, the presence of blood in the resident's urine, the resident's moaning and yelling, her lethargy, and/or of the overall change in the resident's condition prior to [DATE]. .",2014-03-01
11417,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2010-11-17,323,G,,,TRO311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed medical record review, review of facility records, staff interview, resident interview, review of the manufacturer's instructions for operating a sit-to-stand lift, observation, and demonstration by staff of the proper use of a sit-to-stand mechanical lift, the facility failed to ensure one (1) of eighteen (18) sampled residents received adequate supervision and assistance devices to prevent avoidable accidents. Resident #54 fell during a transfer using a sit-to-stand lift, sustaining a fracture to the right femur which resulted in hospitalization and surgical repair of the fracture. The two (2) nursing assistants who were involved in the transfer did not use the equipment in accordance with the manufacturer's instructions to ensure a safe transfer, by failing to ensure the legs of the lift were in the maximum open position for stability during the transfer. The facility also failed to ensure the lift used for transferring Resident #54 was the most appropriate device in view of the fact that the resident was not always able to bear the majority of her own weight, and the legs of the lift could not be opened to the maximum open position for stability when placed under the resident's electric bed, both of which were required by the manufacturer's instructions. Resident identifier: #54. Facility census: 98. Findings include: a) Resident #54 Closed record review revealed Resident #54 was a [AGE] year old female who was originally admitted to the facility on [DATE] for aftercare of surgical repair to a fractured femur. According to her comprehensive admission assessment with an assessment reference date (ARD) of 08/24/09, she was alert, oriented, and independent with cognitive skills for daily decision-making, her [DIAGNOSES REDACTED]. Under ""Test for Balance"" at Item G3a, the assessor encoded ""3"" for ""Not able to attempt test"". Under ""Range of Motion"" and ""Voluntary Movement"" at Items G4dA and G4dB, the assessor indicated the resident had limitations to range of motion with one (1) leg with partial loss of voluntary movement. In Section K, the assessor noted she was 5' 1"" tall and weighed 296#. According to her most recent abbreviated quarterly assessment with an ARD of 05/12/10, in Section G, the assessor noted Resident #54 required the extensive physical assistance of two (2) or more staff for bed mobility, and she was totally dependent on two (2) or more staff for transfers. Under ""Test for Balance"" at Item G3a, the assessor encoded ""3"" for ""Not able to attempt test"". Under ""Range of Motion"" and ""Voluntary Movement"" at Items G4dA and G4dB, the assessor indicated the resident had limitations to range of motion in both legs with partial loss of voluntary movement. In Section K, the assessor noted she was 5' 1"" tall and weighed 298#. Review of her care plan revealed the following problem statement with an initiation date of 05/18/10: ""Resident at risk for falls r/t (related to) decreased mobility and weakness. (sic) hx (history) of falls and med usage."" The goal associated with this problem statement, with a target date of 08/18/10, was: ""Will have no injury r/t falls thru next review."" Interventions to achieve this goal included: ""up (sic) with sit to stand lift for all transfes (sic) wbat (weight bearing as tolerated) per orders."" Review of her physician orders [REDACTED]."" -- A nursing note, recorded by Employee #104 (a registered nurse) and dated 08/15/10 at 12:45 p.m. revealed, ""Called to resident room. Resident was holding onto bar of sit to stand with hands. Left leg was stretched under bed and right leg was twisted with knee cap facing out and foot up by chin. Resident was lowered to floor. Unable to move by staff and squad called to assist resident. 4 squad members and 2 RN (sic), 1 LPN, (sic) 2 CNA (sic) assisted resident on back board and stretcher. Support provided to right leg. When getting resident out of bed with sit to stand lift (per orders). Resident stated, I am not in w/c (wheelchair) right. Staff lifted her up with lift and she said she was sliding. When attempting to get back in bed, bed was too high and unable to lower further down. She let go of lift with one hand. Staff instructed resident to hold on then she let go with the other hand and slid to the floor. Unable to obtain VS (vital signs) due to positioning. ..."" -- A review of the facility's Fall Investigation / QA Report found Resident #54 fell from a sit-to-stand lift at 12:45 p.m. on 08/15/10. The resident was transported to local hospital where she was diagnosed with [REDACTED]. She was subsequently readmitted to the facility on [DATE], and she was discharged to another nursing facility at her request on 10/22/10. A hospital operation summary, dated 08/19/10, stated, ""The patient is a [AGE] year-old female who is known to me. Approximately a year ago, she sustained an intertrochanteric hip fracture while getting out of bed. ... She was admitted to an outside hospital and found to have a subtrochanteric femur fracture as above. She is extremely and morbidly obese. She does not really ambulate and has not ambulated for some time because of this. ..."" -- The facility's investigative report of the fall on 08/15/10 included statements from staff present during the fall and from staff summoned to the resident's room after the fall, as follows: In a statement dated 08/15/10 at 12:15 p.m., Employee #92 (a nursing assistant) wrote: ""We were getting resident out of bed and had her hooked up on the sit to stand lift. We were trying to get her into wheel chair (sic) and we lowered her and she said she wasn't in chair (sic) right. We lifted her up and she said that she was sliding (sic) to get her onto the bed. We got her back to the side of the bed but (sic) bed was to (sic) high. We had no way of lowering the bed. (Electric) (sic) She let go of one hand and said she couldn't hold on. She then let go with other hand and slid down to the floor."" In a statement dated 08/15/10 at 12:15 p.m., Employee #134 (a nursing assistant) wrote: ""When getting resident out of bed with sit and stand lift, we put resident in chair and she said she wasn't in right (sic), we lifted he (sic) back up then she started sliding, When (sic) we tried to put her on her bed, bed (sic) wouldn't lower and she was sliding more (sic) so we had to lower her to floor. Resident let go of lift with one hand and (sic) made her slide more."" In a statement dated 08/15/10 at ""12:15 about"" (per the author of the statement), Employee #22 (a nursing assistant) wrote: ""I (name) was called to (initials) by another CNA (certified nursing assistant). When I entered (sic) resident was lying on floor face down with lift still attached to her. With help from 3 RNs & CNAs we lowered her to the floor completely to try to make resident as comfortable as possible until emergency squad arrived, then was (sic) asked to assist squad members to get resident on back board & out to emergency squad (sic)."" In a statement dated 08/15/10 (no time noted), Employee #81 (a nursing assistant) wrote: ""CNA yelled for help. I entered room and resident had slipped through the sit to stand sling. We lowered (sic) to floor. Ambulance arrived."" In a statement signed on 08/18/10, Employee #135 (a registered nurse - LPN) wrote: ""Called to resident's room by CNAs. Resident was in position of left leg stretched behind her & right leg twisted /c (with) foot by chin. When questioned what happened (sic) resident stated 'I slid in the lift, I let go of bar.' Denied pain @ (at) that time. Was sent to ER (sic) for eval."" In a statement dated 08/16/10 at 12:30 p.m., Employee #109 (a licensed practical nurse - LPN) wrote: ""On 8/15/10 ~ 12:45 p called to residents (sic) room by staff. Resident lying on abdomen in center of floor /c (R) (right) leg bent & extended out & upwards towards (R) side. Multiple staff members in room to assist. Squad notified, arrived & called for extra squad members to assist /c transport. ... Upon arrival of 2nd squad & instructions received from their Command Center, resident transferred onto backboard on abd (abdomen) /c leg supported by 8 staff & squad to cot. ..."" There was no evidence to reflect the facility had interviewed the resident during their internal investigation of this fall, even though she was alert and oriented, she had been determined to possess the capacity to make her own informed medical decisions, and she returned to the facility after her hospital stay on 08/24/10. (See also citation at F225.) -- An interview with Employee #121 (a registered nurse), on 11/15/10 at 12:55 p.m., revealed the RN was called to the resident's room. She walked into the room and saw the resident lying on her abdomen with her right leg under her and her foot up under her chin. The other staff in the room told the nurse that the resident was being transferred from the bed and the resident changed her mind about getting up in the chair. She felt weak and let go of the bar on the sit to stand and slipped through the sling. She further stated, ""The resident sustained [REDACTED]."" -- An interview with the administrator, on 11/15/10 at 2:00 p.m., revealed the resident had been transferred to the wheelchair from her bed and slid out of the sit-to-stand lift when she requested to be put back to bed. He stated his belief that the two (2) nursing assistants did the transfer the resident properly, and the fall was an accident. -- An interview with the physical therapist, at 9:15 a.m. on 11/16/10, revealed he had discharged Resident #54 from therapy in June of 2010, and the therapy staff had utilized the sit-to-stand lift for transferring the resident. He further stated if a resident was feeling weak, the staff should use a Hoyer lift, because the resident needed to have the strength to hold onto the bars with the sit-to-stand lift. -- In a telephone interview on 11/16/10 at 9:55 a.m., Resident #54 (who now resides in another facility) reported that she looked down during the transfer while seated in the lift and noticed the back wheel bending under. The next thing she remembered was the bar on the lift moving at an angle and then she was on the floor. She stated that the sit-to-stand lift was broken and was placed out of service for repair and, somehow, the lift was used the day she was injured. She also stated, ""I never said that I was weak and did not change my mind about sitting in the chair. The lift was not working properly and turned over with me still in the sling."" -- An interview with the maintenance supervisor (Employee #70), on 11/16/10 at 10:00 a.m., revealed he thought that a sit-to-stand lift was taken out of service in August and there would be a work order for the repairs. He further stated the spring apparatus was not working properly and would not allow the legs to stay in the open position. He said he would go and look for the work order. At 3:00 p.m., the maintenance supervisor stated that a Hoyer lift was the equipment that needed to be repaired, not the sit-to-stand lift. -- An interview, on 11/16/10 at 10:35 a.m., with the two (2) nursing assistants involved in the transfer (Employees #92 and #134) revealed, ""The resident was being transferred in the sit-to-stand lift from the resident's bed. The resident was in an electric bed, and when we had her get into the sit-to-stand lift, she said she was not in the seat right. We situated her in the seat again and moved the lift with the resident seated from under the bed. We had the legs of the lift in the straight position. The legs were not opened, and we attempted to move the resident. She let go of the bars on the lift and slid out onto the floor."" -- A review of the ""Owner's Operating and Maintenance"" manual for the Invacare Stand Up Lift - Model RPS350-1(referred to by staff as the ""sit-to-stand lift"") revealed a ""Safety Summary"" on pages 4 and 5, which included the following in a box labeled ""Warning"": ""DO NOT attempt any transfer without approval of the patient's physician, nurse or medical assistant. Thoroughly read the instructions in this Owner's Manual, observe a trained team of experts perform the lifting procedures and then perform the entire lift procedure several times with proper supervision and a capable individual acting as a patient. ""Individuals that use the Standing Sling (Model R130) MUST be able to support the majority of their own weight, otherwise injury can occur. ..."" In the section titled ""Transferring From"" on page 10, under the heading ""Lifting the Patient (Figure 1)"" were the following instruction to be performed before raising a resident above the surface being transferred from: ""F. Make sure the legs (of the lift) are in the maximum open position and the shifter handle is locked in place."" In the above noted interview, Employees #92 and #134 stated the legs of the lift were closed (not in the ""maximum open position"") during the transfer of Resident #54, contrary to the manufacturer's instructions. -- At 11:40 a.m. on 11/16/10, the director of nursing (DON - Employee #88) demonstrated the proper use of the sit-to-stand lift, stating the legs of the lift must be in the fully opened position when a resident is in the lift to provide stability for safe use. The DON stated, ""When a resident is in the lift, the legs (of the lift) are to be opened to the maximum width. The staff knows that they never have the legs closed with a resident in the sit-to-stand."" She further stated, ""We have some electric beds, and the sit-to-stand lift will not fit under the bed with the legs in the maximum open position. The legs will not go under the bed or you can't remove the sit-to-stand (lift) from under the bed in the open position."" Observation of an electric bed verified the bed frame would not permit the legs of the sit-to-stand lift to open when placed under the bed. .",2014-03-01
11418,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2010-11-17,520,E,,,TRO311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility records, resident interview, policy review, and staff interview, 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, and implement plans of action to correct these deficiencies, including monitoring the effect of implemented changes and making revisions to the action plans if the desired results were not obtained. A resident was transferred inappropriately while using the sit-to-stand lift; the legs of the lift were not placed in the maximum open position for stability prior to lifting the resident to/from an electric bed; the resident fell during this transfer and sustained a [MEDICAL CONDITION]. Following the fall, the facility completed an internal investigation which included obtaining witness statements from various employees. However, the facility did not interview the affected resident, who was alert / oriented, possessed the capacity to understand and make informed health care decisions, and who returned to the facility and was available to be interviewed following the surgical repair of her fracture. In spite of the fact the topics of incident / accident report review and abuse / neglect reporting and investigation were identified as being permanent items on the QAA committee's agenda, existing quality deficiencies were not effectively addressed to ensure resident accidents and/or neglect (related to inappropriate care / services provided) were thoroughly investigated. In addition, the facility's internal investigation contained statements by staff alluding to difficulties using the sit-to-stand lift in conjunction with an electric bed, but the facility's QAA committee failed to explore this concern and implement measures (e.g., staff training) to prevent recurrence. These practices have the potential to result in more than minimal harm to all residents. Facility census: 98. Findings include: a) Review of facility abuse / neglect self-reporting to State officials, on 11/11/10 at 9:30 a.m., revealed an incident that took place on 08/15/10 and was reported to the Office of Health Facility Licensure and Certification (OHFLAC, the State survey and certification agency) as an ""unusual occurrence"". Resident #54 sustained a fracture during an attempted transfer using a sit-to-stand lift. Documentation on the ""Immediate Fax Reporting of Allegations"" form, in the section headed ""Brief description of the incident"", stated: ""Called to resident's room by staff. Resident holding on to bar of sit to stand (sic) with hands. Left leg was stretched under bed and right leg twisted with kneecap out and foot up by chin. Resident lowered to floor and squad called to take resident to ER (emergency room ) for eval."" This form was signed by a registered nurse (RN - Employee #135). - The ""Five-day Follow-up"" form was completed on 08/18/10 by the facility's social worker (Employee #142). Documentation in the section headed ""Outcome / Results of Investigation"" stated: ""Unusual occurrence - resident slid during attempted transfer. No indication that maltreatment occurred. Resident stated that she let go of handle bar of lift (sit to stand)."" There was no documented interview with the resident, who had been determined to possess the capacity to make informed medical decisions. - Two (2) written statements were included with the facility's reports from the nursing assistants who had been attempting the transfer. In a statement dated 08/15/10 at 12:15 p.m., Employee #92 (a nursing assistant) wrote: ""We were getting resident out of bed and had her hooked up on the sit to stand lift. We were trying to get her into wheel chair (sic) and we lowered her and she said she wasn't in chair (sic) right. We lifted her up and she said that she was sliding (sic) to get her onto the bed. We got her back to the side of the bed but (sic) bed was to (sic) high. We had no way of lowering the bed. (Electric) (sic) She let go of one hand and said she couldn't hold on. She then let go with other hand and slid down to the floor."" In a statement dated 08/15/10 at 12:15 p.m., Employee #134 (a nursing assistant) wrote: ""When getting resident out of bed with sit and stand lift, we put resident in chair and she said she wasn't in right (sic), we lifted he (sic) back up then she started sliding, When (sic) we tried to put her on her bed, bed (sic) wouldn't lower and she was sliding more (sic) so we had to lower her to floor. Resident let go of lift with one hand and (sic) made her slide more."" - Review of all documentation associated with the facility's internal investigation found it was unclear how Resident #54 ended up on the floor. Employee #92 stated, ""She then let go with the other hand and slid down to the floor."" The description by the RN (Employee #135) stated, ""Resident holding on to bar of sit to stand with hands. Left leg was stretched under bed and right leg twisted with kneecap out and foot up by chin. Resident lowered to floor ... "" There was no evidence of any investigation into statements by staff members of problems with using the sit-to-stand lift when transferring residents into and out of an electric bed, which apparently contributed to the resident's fall. -- b) A review of facility incident / accident reports, on 11/15/10 at 10:30 a.m., revealed an incident report for Resident #54 categorized as a fall, which documented the incident of 08/15/10 at 12:45 p.m. Documentation in the section headed ""Describe the circumstances of the event and what actions, if any have been taken currently"" stated, ""Called to resident's room by staff. Resident holding on to bar of sit to stand with hands. Left leg was stretched under bed and right leg twisted with kneecap out and foot up by chin. Resident was lowered to floor. Unable to move by staff and and squad was called to assist resident. 4 squad members and 2 RN, 1 LPN, 2 CNA (certified nursing assistants) assisted resident on back board and stretcher, support provided to right leg. When getting resident out of bed with sit to stand lift (per orders). Resident stated 'I am not in w/c (wheelchair) right.' Staff lifted her up with lift and she said she was sliding. When attempting to get back in bed, bed was too high and unable to lower further down. She let go of lift with one hand. Staff instructed resident to hold on then she let go with the other hand and slid to the floor, unable to obtain VS (vital signs) D/T (due to) positioning."" Documentation in the section headed ""Recommendations to prevent further falls"" stated: ""Use mechanical lift for transfers."" A hand written statement was attached to the report, composed by an RN (#111) and dated 08/16/10. It stated: ""(Name of Employee #92), (name of Employee #134), and (name of Employee #81) were re-educated on the sit to stand lift following the (name of Resident #54) fall (sic) RMS (Risk Management System) # 1."" There was no apparent investigation of the problem of using a sit-to-stand lift in conjunction with an electric bed. There was no reason given why it was recommended that a mechanical lift should be used with Resident #54 after the fall, instead of the sit-to-stand lift. There was no documented interview with the resident, who had been determined to possess the capacity to make informed medical decisions. There was no explanation as to why it was necessary to provide re-education to only these three (3) employees (if nothing had been done improperly); if any re-education were felt to be warranted, there was no explanation as to why this re-education was not then provided to all staff that might use the sit-to-stand lift. -- c) Record review revealed Resident #54 was a [AGE] year old female who was 5' 1"" tall and weighed between 280# and 301# during her residency in this facility; at the time of this survey event, Resident #54 resided in another facility. Resident #54 was interviewed via telephone at 9:55 a.m. on 11/16/10. She was asked about the incident of 08/15/10, which she said she recalled clearly. She stated that, when she was being moved in the lift, the lift tipped or lurched, causing her ""to go over"". She also reported her belief that the lift was broken at the time is was being used. -- d) During an interview with the director of nursing (DON - Employee #88) on 11/16/10 at 11:00 a.m., she stated there were some beds in the facility with which the sit-to-stand lift could not be used. She said the sit-to-stand lift could not be used with the electric beds, because the legs of the lift could not be fully opened when they were under the bed. She demonstrated the proper use of the sit-to-stand lift, stating the legs of the lift must be in the fully opened position when a resident is in the lift to provide stability for safe use. -- e) The manufacturer's operating manual for the sit-to-stand lift was reviewed at 10:00 a.m. on 11/16/10. In the section headed ""Lifting the patient"", was Step F, which stated: ""Make sure the legs are in the maximum open position and the shifter handle is locked in place."" -- f) An interview was conducted, on 11/16/10 at 10:29 a.m., with the two (2) nursing assistants involved in the above-referenced event (Employees #92 and #134). They both stated that the legs of the sit-to-stand lift were not in the open position when they lifted Resident #54 from the bed and attempted to transfer her to the wheelchair and back. -- g) The facility's administrator (Employee #28), when interviewed on 11/15/10 at 2:30 p.m., was asked if the facility's QAA committee had topics that were always placed on the agenda for discussion by the committee members. He related there were items looked at in every meeting, which included past survey results, customer base, incidents / accidents, abuse / neglect reporting, medication errors, and department-specific topics related to their operations. Discrepancies found by the surveyor during an investigation into the events of 08/15/10, which included a review of written statements obtained by the facility from individual staff members, information obtained by the surveyor through interviews with staff members and a telephone interview with Resident #54, and a review of facility documentation, identified concerns related to the use by staff of the sit-to-stand lift during Resident #54's transfer resulting in a [MEDICAL CONDITION]. These discrepancies were discussed with the administrator, who was asked to provide to the surveyor any additional documentation not previously produced, to demonstrate the circumstances of Resident #54's transfer and fall were reviewed by facility management and/or the QAA committee and steps were taken to ensure no other residents were injured in the future during the use of the sit-to-stand lift. He voiced understanding and stated he had spoken with Resident #54 following the events of 08/15/10, and that she had not said anything to him about the lift tipping or lurching. He stated he had notes of this conversation. He subsequently provided: (1) a ""Customer First Ambassador Rounds Worksheet"", which he stated was the discussion with the resident when she returned from the hospital; (2) the facility's incident report of 08/15/10; and (3) a policy entitled ""Resident / Patient Lifting / Transfer"". - Upon review of Resident #54's ""Customer First Ambassador Rounds Worksheet"", this form consisted of observations and interviews conducted by the social worker (Employee #142) on 08/25/10, 08/26/10, 08/27/10, 09/13/10, 09/15/10, and 09/17/10. The interview questions were general satisfaction items, such as ""Was the food appetizing in taste?"", ""Has the housekeeping staff kept you room to your satisfaction?"", ""Has the staff been taking good care of you?"" The observations were also general in nature, covering areas such as hygiene and grooming, environment, and water pitchers. There was nothing found that addressed the incident of 08/15/10. - Review of the facility incident report provided by the administrator found that additional pages were attached, to include a cover sheet containing the signatures of the administrator and the DON, indicating they had reviewed the investigation of the incident. - Review of the facility's ""Resident / Patient Lifting / Transfer"" policy found it covered all aspects of lifting and transfer. The only specific mention of the sit-to-stand lift was under Section 4 for ""Equipment"", which stated: ""Sit to-Stand Lifts - designed to assist the caregiver in standing a resident / patient up, without the need for any manual lifting. The resident / patient only needs minimal weight bearing ability to be transferred easily from bed to toilet or chair."" There were no specific policies or procedures presented regarding appropriate use and safe operation of the sit-to-stand lift. There was no documented training or education provided to address whether the sit-to-stand lift should not be used with some beds (e.g., electric) or that the legs of the lift must be fully opened before lifting a resident.",2014-03-01
11419,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2010-11-17,225,D,,,TRO311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed medical record review, review of facility records, staff interview, resident interview, review of the manufacturer's instructions for operating a sit-to-stand lift, observation, and demonstration by staff of the proper use of a sit-to-stand mechanical lift, the facility failed to conduct a thorough investigation, and make a report to the Nurse Aide Registry of two (2) nursing assistants, of neglect involving one (1) of eighteen (18) sampled residents who was injured during an unsafe transfer. Resident #54 fell during a transfer using a sit-to-stand lift, sustaining a fracture to the right femur which resulted in hospitalization and surgical repair of the fracture. The facility's internal investigation into this fall was not thorough as evidenced by a failure to conduct an interview with the affected resident, who was alert and oriented and available for interview upon her return from the hospital to the facility; when interviewed by a surveyor, the resident related information markedly different from what had been reported by staff involved in the incident. The facility also failed to identify during its investigation that the sit-to-stand lift was not used in accordance with the manufacturer's instructions. The two (2) nursing assistants who were involved in the transfer failed to ensure the legs of the sit-to-stand lift were in the maximum open position for stability prior to attempting to transfer the resident. The facility did not identify this as neglect and/or report the individuals involved to the appropriate State agencies as required. Resident identifier: #54. Facility census: 98. Findings include: a) Resident #54 Closed record review revealed Resident #54 was a [AGE] year old female who was originally admitted to the facility on [DATE] for aftercare of surgical repair to a fractured femur. According to her comprehensive admission assessment with an assessment reference date (ARD) of 08/24/09, she was alert, oriented, and independent with cognitive skills for daily decision-making, her [DIAGNOSES REDACTED]. Under ""Test for Balance"" at Item G3a, the assessor encoded ""3"" for ""Not able to attempt test"". Under ""Range of Motion"" and ""Voluntary Movement"" at Items G4dA and G4dB, the assessor indicated the resident had limitations to range of motion with one (1) leg with partial loss of voluntary movement. In Section K, the assessor noted she was 5' 1"" tall and weighed 296#. According to her most recent abbreviated quarterly assessment with an ARD of 05/12/10, in Section G, the assessor noted Resident #54 required the extensive physical assistance of two (2) or more staff for bed mobility, and she was totally dependent on two (2) or more staff for transfers. Under ""Test for Balance"" at Item G3a, the assessor encoded ""3"" for ""Not able to attempt test"". Under ""Range of Motion"" and ""Voluntary Movement"" at Items G4dA and G4dB, the assessor indicated the resident had limitations to range of motion in both legs with partial loss of voluntary movement. In Section K, the assessor noted she was 5' 1"" tall and weighed 298#. Review of her care plan revealed the following problem statement with an initiation date of 05/18/10: ""Resident at risk for falls r/t (related to) decreased mobility and weakness. (sic) hx (history) of falls and med usage."" The goal associated with this problem statement, with a target date of 08/18/10, was: ""Will have no injury r/t falls thru next review."" Interventions to achieve this goal included: ""up (sic) with sit to stand lift for all transfes (sic) wbat (weight bearing as tolerated) per orders."" Review of her physician orders [REDACTED]."" -- A nursing note, recorded by Employee #104 (a registered nurse) and dated 08/15/10 at 12:45 p.m. revealed, ""Called to resident room. Resident was holding onto bar of sit to stand with hands. Left leg was stretched under bed and right leg was twisted with knee cap facing out and foot up by chin. Resident was lowered to floor. Unable to move by staff and squad called to assist resident. 4 squad members and 2 RN (sic), 1 LPN, (sic) 2 CNA (sic) assisted resident on back board and stretcher. Support provided to right leg. When getting resident out of bed with sit to stand lift (per orders). Resident stated, I am not in w/c (wheelchair) right. Staff lifted her up with lift and she said she was sliding. When attempting to get back in bed, bed was too high and unable to lower further down. She let go of lift with one hand. Staff instructed resident to hold on then she let go with the other hand and slid to the floor. Unable to obtain VS (vital signs) due to positioning. ..."" -- A review of the facility's Fall Investigation / QA Report found Resident #54 fell from a sit-to-stand lift at 12:45 p.m. on 08/15/10. The resident was transported to local hospital where she was diagnosed with [REDACTED]. She was subsequently readmitted to the facility on [DATE], and she was discharged to another nursing facility at her request on 10/22/10. -- The facility's investigative report of the fall on 08/15/10 included statements from staff present during the fall and from staff summoned to the resident's room after the fall, as follows: In a statement dated 08/15/10 at 12:15 p.m., Employee #92 (a nursing assistant) wrote: ""We were getting resident out of bed and had her hooked up on the sit to stand lift. We were trying to get her into wheel chair (sic) and we lowered her and she said she wasn't in chair (sic) right. We lifted her up and she said that she was sliding (sic) to get her onto the bed. We got her back to the side of the bed but (sic) bed was to (sic) high. We had no way of lowering the bed. (Electric) (sic) She let go of one hand and said she couldn't hold on. She then let go with other hand and slid down to the floor."" In a statement dated 08/15/10 at 12:15 p.m., Employee #134 (a nursing assistant) wrote: ""When getting resident out of bed with sit and stand lift, we put resident in chair and she said she wasn't in right (sic), we lifted he (sic) back up then she started sliding, When (sic) we tried to put her on her bed, bed (sic) wouldn't lower and she was sliding more (sic) so we had to lower her to floor. Resident let go of lift with one hand and (sic) made her slide more."" In a statement dated 08/15/10 at ""12:15 about"" (per the author of the statement), Employee #22 (a nursing assistant) wrote: ""I (name) was called to (initials) by another CNA (certified nursing assistant). When I entered (sic) resident was lying on floor face down with lift still attached to her. With help from 3 RNs & CNAs we lowered her to the floor completely to try to make resident as comfortable as possible until emergency squad arrived, then was (sic) asked to assist squad members to get resident on back board & out to emergency squad (sic)."" In a statement dated 08/15/10 (no time noted), Employee #81 (a nursing assistant) wrote: ""CNA yelled for help. I entered room and resident had slipped through the sit to stand sling. We lowered (sic) to floor. Ambulance arrived."" In a statement signed on 08/18/10, Employee #135 (a registered nurse - LPN) wrote: ""Called to resident's room by CNAs. Resident was in position of left leg stretched behind her & right leg twisted /c (with) foot by chin. When questioned what happened (sic) resident stated 'I slid in the lift, I let go of bar.' Denied pain @ (at) that time. Was sent to ER (sic) for eval."" In a statement dated 08/16/10 at 12:30 p.m., Employee #109 (a licensed practical nurse - LPN) wrote: ""On 8/15/10 ~ 12:45 p called to residents (sic) room by staff. Resident lying on abdomen in center of floor /c (R) (right) leg bent & extended out & upwards towards (R) side. Multiple staff members in room to assist. Squad notified, arrived & called for extra squad members to assist /c transport. ... Upon arrival of 2nd squad & instructions received from their Command Center, resident transferred onto backboard on abd (abdomen) /c leg supported by 8 staff & squad to cot. ..."" There was no evidence to reflect the facility had interviewed the resident during their internal investigation of this fall, even though she was alert and oriented, she had been determined to possess the capacity to make her own informed medical decisions, and she returned to the facility after her hospital stay on 08/24/10. -- An interview with Employee #121 (a registered nurse), on 11/15/10 at 12:55 p.m., revealed the RN was called to the resident's room. She walked into the room and saw the resident lying on her abdomen with her right leg under her and her foot up under her chin. The other staff in the room told the nurse that the resident was being transferred from the bed and the resident changed her mind about getting up in the chair. She felt weak and let go of the bar on the sit to stand and slipped through the sling. She further stated, ""The resident sustained [REDACTED]."" -- An interview with the administrator, on 11/15/10 at 2:00 p.m., revealed the resident had been transferred to the wheelchair from her bed and slid out of the sit-to-stand lift when she requested to be put back to bed. He stated his belief that the two (2) nursing assistants did the transfer the resident properly, and the fall was an accident. He believed the staff involved was not negligent during the transfer, and he verified the two (2) nursing assistants were not reported to the Nurse Aide Registry. -- An interview with the physical therapist, at 9:15 a.m. on 11/16/10, revealed he had discharged Resident #54 from therapy in June of 2010, and the therapy staff had utilized the sit-to-stand lift for transferring the resident. He further stated if a resident was feeling weak, the staff should use a Hoyer lift, because the resident needed to have the strength to hold onto the bars with the sit-to-stand lift. -- In a telephone interview on 11/16/10 at 9:55 a.m., Resident #54 (who now resided in another facility) reported that she looked down during the transfer while seated in the lift and noticed the back wheel bending under. The next thing she remembered was the bar on the lift moving at an angle and then she was on the floor. She stated that the sit-to-stand lift was broken and was placed out of service for repair and, somehow, the lift was used the day she was injured. She stated, ""I never said that I was weak and did not change my mind about sitting in the chair. The lift was not working properly and turned over with me still in the sling."" -- An interview with the maintenance supervisor (Employee #70), on 11/16/10 at 10:00 a.m., revealed he thought that a sit-to-stand lift was taken out of service in August and there would be a work order for the repairs. He further stated the spring apparatus was not working properly and would not allow the legs to stay in the open position. He said he would go and look for the work order. At 3:00 p.m., the maintenance supervisor stated that a Hoyer lift was the equipment that needed to be repaired, not the sit-to-stand lift. -- An interview, on 11/16/10 at 10:35 a.m., with the two (2) nursing assistants involved in the transfer (Employees #92 and #134) revealed, ""The resident was being transferred in the sit-to-stand lift from the resident's bed. The resident was in an electric bed, and when we had her get into the sit-to-stand lift, she said she was not in the seat right. We situated her in the seat again and moved the lift with the resident seated from under the bed. We had the legs of the lift in the straight position. The legs were not opened, and we attempted to move the resident. She let go of the bars on the lift and slid out onto the floor."" -- A review of the ""Owner's Operating and Maintenance"" manual for the Invacare Stand Up Lift - Model RPS350-1(referred to by staff as the ""sit-to-stand lift"") revealed, in the section titled ""Transferring From"" on page 10, under the heading ""Lifting the Patient (Figure 1)"", the following instruction to be performed before raising a resident above the surface being transferred from: ""F. Make sure the legs (of the lift) are in the maximum open position and the shifter handle is locked in place."" In the above noted interview, Employees #92 and #134 stated the legs of the lift were closed (not in the ""maximum open position"") during the transfer of Resident #54. -- At 11:40 a.m. on 11/16/10, the director of nursing (DON - Employee #88) demonstrated the proper use of the sit-to-stand lift, stating the legs of the lift must be in the fully opened position when a resident is in the lift to provide stability for safe use. The DON stated, ""When a resident is in the lift, the legs (of the lift) are to be opened to the maximum width. The staff knows that they never have the legs closed with a resident in the sit-to-stand."" She further stated, ""We have some electric beds, and the sit-to-stand lift will not fit under the bed with the legs in the maximum open position. The legs will not go under the bed or you can't remove the sit-to-stand (lift) from under the bed in the open position."" Observation of an electric bed verified the bed frame would not permit the legs of the sit-to-stand lift to open when placed under the bed. .",2014-03-01
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
11428,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2010-11-11,241,D,,,6V1A11,". Based on observation, resident interview, and staff interview, the facility failed to promote care for one (1) of four (4) residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Observation and interview revealed one (1) resident did not receive prompt assistance with incontinence care during a meal time. Resident identifier: #77. Facility census: 141. Findings include: a) Resident #77 Observation, on 11/11/10 at approximately 8:35 a.m., found Resident #77 turned on his call light. When interviewed, he reported he needed to be cleaned up. The resident said, ""I am in a mess."" At approximately 8:40 a.m., the resident's call light went off. At approximately 8:45 a.m., Employee #130 (a nurse aide) said she told the resident she would clean him up after she finished picking up the breakfast trays. On 11/11/10 at approximately 10:45 a.m., the interim director of nursing indicated he had spoken with this nurse aide, and Employee #130 did realize she should have provided Resident #77 with the assistance he needed before she finished picking up the breakfast trays. He agreed the resident's needs should have come before picking up trays after the breakfast meal. .",2014-03-01
11429,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,314,G,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of product information found on the Internet, and staff interview, the facility failed to provide care and services for one (1) of eleven (11) residents reviewed, to prevent the development of new pressure sores for a resident who entered the facility without a pressure sore. Resident #50, who was admitted to the facility on [DATE] with intact skin, was totally dependent upon staff for bed mobility and transferring, and was identified as being at high risk for developing pressure sores. The interdisciplinary team identified her risk for developing skin breakdown in her care plan dated 06/21/10, and approaches to be implemented by staff to prevent skin breakdown included conducting weekly body audits. On 08/13/10, a nursing assistant identified Resident #50 as having a ""blackened area"" on her left heel. Weekly body audits were not completed in accordance with her plan of care, and the presence of this skin breakdown was not identified and treated at an earlier stage. Facility census: 84. Findings include: a) Resident #50 Record review revealed this [AGE] year old female resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]., and [MEDICAL CONDITION] bladder. The resident's admission nursing assessment, dated as completed on 06/03/10, stated the resident had no skin breakdown present on admission. This document also stated the resident was totally dependent on staff for transfers and she was non-weight bearing. The resident was also incontinent of bowel and had an indwelling Foley catheter at that time (which was removed on 08/15/10). The resident's pressure ulcer risk assessment, completed on 06/03/10, rated her as ""10"", indicating she was at high risk for developing pressure sores. According to her comprehensive admission assessment with an assessment reference date (ARD) of 06/10/10, she was alert but not oriented, with short and long term memory problems and moderately impaired cognitive skills for daily decision making. She was totally dependent on staff for bed mobility, transfers, and toilet use, and she was to be transferred using a mechanical lift. She had no pressure sores during the assessment reference period. Review of the resident's care plan found the following problem statement with an onset date of 06/21/10: ""Potential risk for skin breakdown d/t (due to) decreased physical mobility."" The goal associated with this problem statement was: ""Maintain intact skin integrity thru 09/21/10."" Approaches to be implemented to meet this goal included: ""up (sic) in geri chair as tolerated. weekly (sic) body audit. Provide diet as ordered ... Reposition resident every 2 or 3 hours and PRN (as needed). Instruct resident / family on consequences of noncompliance with therapeutic regime (sic). Cleanse perineal area with peri wash following each bowel and/or bladder episode."" -- Review of the facility's incident / accident reports, on 11/09/10, found an Incident Investigation Report involving Resident #50 and dated 10:00 a.m. on 08/13/10. Under the heading ""Describe Circumstances of the Incident (Be very specific):"" was written, ""CNA (certified nursing assistant) (initials) notified this nurse of discoloration area to Resident's (Lt) (left) heel, black in color, measures 2.5 cc diameter (sic) soft to touch. Resident has poor bed mobility. Dr. (name) in facility and aware. New order [MEDICATION NAME] apply (sic) (Lt) heel q (every) shift. Heel lift boots (sic) @ (at) all times."" Under the heading ""Analysis of the Incident: (apparent cause)"" was written, ""Poor bed mobility."" Under the heading ""Describe Corrective action (sic) or Protective Action Taken: (be specific)"" was written: ""[MEDICATION NAME] Apply (Lt) heel q shift. Heel lift boots @ all times."" -- Product information for [MEDICATION NAME] (found on the Internet at http://www.udllabs.com/pdfs/[MEDICATION NAME].pdf) revealed the following ""Uses"" for [MEDICATION NAME]: - ""Management of decubitus ulcers."" - ""Forms protective barrier and speeds healing by increasing capillary blood flow into the ulcerated area. "" - Product information for Heelift Suspension Boots (found on the Internet at http://www.heelift.com/) revealed the following product claims: "" The Heelift ? completely eliminates pressure as the heel is floated in protective space. Studies prove Heelift Suspension Boots provide a pressure-free environment to help eliminate and prevent pressure ulcers. "" -- On 11/10/10 at 11:00 a.m., the facility's unit supervisor (Employee #66) was asked to provide evidence to reflect this resident received weekly body audits in an effort to avoid skin breakdown. After review of facility documents, Employee #66 was only able to produce evidence that weekly body audits were performed on Resident #50 on the following Wednesdays: 06/09/10, 06/16/10, and 07/28/10. Employee #66 confirmed there were no additional body audits for this resident. The blackened area to the heel was discovered on 08/13/10. Based on the documentation presented by Employee #66, Resident #50 did not receive weekly body audits on 08/04/10 or 08/11/10 (before the blackened heel was identified by staff). -- A facility nurse (Employee #72) was interviewed on 11/09/10. When asked how residents were evaluated for skin breakdown, this nurse stated, ""We do weekly body audits."" When further questioned about how an area would not be recognized until it had become black, the nurse stated, ""It should have been caught before it was black."" .",2014-03-01
11430,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,157,D,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, closed medical record review, and staff interview, the facility failed, for one (1) of eleven (11) sampled residents, to notify the resident's legal representative or attending physician of a significant change in the resident's health status. Resident #45, who had a history of [REDACTED]. Beginning on [DATE], Resident #45 was noted to have an increased frequency in bowel elimination with three (3) BMs per shift for the next four (4) consecutive shifts; then her high frequency of BMs continued beginning on the day shift of [DATE]. Staff did not identify this increased frequency of BMs and failed to collect / record, monitor, and report to the physician or the resident's legal representative any physical assessment data related to this resident's change in condition. Staff also did not identify and report to the physician or the resident's legal representative a decrease in Resident #45's daily fluid intake. On the morning of [DATE], after intervention by the resident's legal representative, Resident #45 was transferred to the hospital due to an altered mental status and was subsequently admitted with [MEDICAL CONDITION] (C. diff.) [MEDICAL CONDITION] and proctitis; urinary tract infection [MEDICAL CONDITION]; altered mental status secondary to the above; acute hemorrhagic stroke in the parietal lobe; and dehydration. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 1. During a telephone interview beginning at 5:45 p.m. on [DATE], the daughter of Resident #45 reported that she had visited her mother at the facility and found her with a dry mouth and a foul odor associated with bowel movement and urine; according to her daughter, Resident #45 was not very responsive and could barely say her name. The daughter reported her findings to a nurse at the facility, who ""pinched"" the resident's skin and said she did not believe the resident was dehydrated. The daughter reported her belief that the facility failed to assess her mother for about one (1) week; she had visited her mother on [DATE] and ""everything was fine"", but when she returned on [DATE], she found her mother in a ""gravely ill"" condition. The daughter reported she did not hear from the facility during the period from [DATE] through [DATE] to let her know that her mother was sick. Her mother was not transferred to the hospital until she brought her mother's condition to the staff's attention on [DATE]. Her mother later expired at the hospital on [DATE]. -- 2. Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her nursing notes revealed the last entry was made at 12:05 p.m. on [DATE]. Further review of her record revealed a physician's telephone order dated [DATE] (no time written) to transport the resident to the local hospital's emergency room due to ""(symbol for 'change') in mental status"", although there was no corresponding entry discussing when or why this occurred. (See also citation at F514.) -- 3. Information obtained from the hospital history and physical, electronically signed by the physician on [DATE], revealed Resident #45 arrived at the emergency roiagnom on [DATE], with a chief complaint of ""altered mental status"". Under the heading ""History of Present Illness"" was found: ""This is an [AGE] year old white female who resides at Boone Nursing whose history comes from family as well as nursing staff who report (sic) that she had a (sic) altered mental status since last night. She had a decreased appetite, weakness, and diarrhea for several days. ... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..."" Under the heading ""Physical Examination"" was found: ""... Positive lethargy but no comatose state. Alert. Dehydration with dry mucous membranes. ... Bowel sounds hyperactive. ..."" Under the heading ""Labs"" was found the following abnormal values: glucose 141 (normal range = ,[DATE]); blood urea nitrogen (BUN) 58 (normal range = ,[DATE]); white blood cells 15.3 (normal range = 4XXX,[DATE]); 2+ protein in urine (normal = negative); 2+ leukocyte esterase in urine (normal = negative). Under the heading ""Assessment / Plan"" was found the following: ""1. [DIAGNOSES REDACTED] [MEDICAL CONDITIONS] and proctitis ... ""2. UTI (urinary tract infection) ... ""3. Altered mental status secondary to the above. ""4. Acute hemorrhagic stroke in parietal lobe ... ""5. Dehydration. Given light IV fluids to prevent any kind of fluid overload. ..."" -- 4. Review of Resident #45's nursing notes for [DATE] revealed staff called the physician and obtained an order for [REDACTED]. Review of the nursing notes for [DATE] and [DATE] found no documentation related to the resident's fluid intake and/or bowel elimination, and all nursing documentation stopped after 12:05 p.m. on [DATE]. Review of Resident #45's [DATE] ADL flow sheet revealed she had an extra large BM on the evening shift of [DATE], and then she did not have another BM until the day shift on [DATE], for which a Fleets enema was administered. According to coding on the ADL flow sheet, the resident had two (2) BMs on the day shift of [DATE]. This was followed by: - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; - Three (3) BMs on the day shift of [DATE]; - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - One (1) small BM on the night shift of [DATE]; - One (1) large BM on the day shift of [DATE]; - Two (2) large BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; and - One (1) large BM on the day shift of [DATE]. There was no evidence the licensed nursing staff identified and reported to the physician or the resident's legal representative that this resident, beginning on [DATE], was having excessively frequent BMs. -- 5. According to her [DATE] recapitulation of physician orders, Resident #45's diet order was as follows: ""LCS / NAS (low concentrated sweets / no added salt) diet w/ ground meats. Encourage fluids w/ meals."" To prevent weight loss, Resident #45's orders also included Glucerna 1 can by mouth twice daily and Med Pass 120 cc by mouth twice daily. According to her care plan, Resident #45 was ""at risk for weight loss"" related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus. Interventions for maintaining her weight at plus / minus 5# through the next review included: ""Encourage fluids with meals."" According to her weight record on [DATE], Resident #45 weighed 196# (89.1 kg). Her estimated daily fluid needs, based on a formula of 30 cc/kg, would be 2673 cc of fluid per day. Review of the ADL flow sheets for September and [DATE] revealed Resident #45 consumed 600 cc or less per day as follows: - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 520 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1240 cc) - [DATE] - 480 cc with meals and snacks; 240 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 840 cc) - [DATE] - 360 cc with meals and snack; 480 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 960 cc) - [DATE] - ADL flow sheet documentation showed resident refused all fluids offered on day shift; 240 cc of Glucerna; 0 cc of Med Pass (total fluids on day shift prior to transfer to hospital = 240 cc) Review of the medical record, on [DATE] at 11:15 a.m., found no evidence to reflect the licensed nursing staff identified the resident's inadequate fluid intake and notified the physician or Resident #45's legal representative. -- 6. Resident #45 was sent out to the hospital on day shift on [DATE], but no nursing documentation was found related to assessment of the resident prior to her being sent to the hospital. According to her hospital record, she was admitted for [DIAGNOSES REDACTED], [MEDICAL CONDITION], proctitis, urinary tract infection [MEDICAL CONDITION], dehydration, leukocytosis secondary to [DIAGNOSES REDACTED] and UTI, altered mental status secondary to [DIAGNOSES REDACTED] and UTI, hypercalcemia, acute hemorrhagic stroke in the parietal lobe, and lactic acid elevation. -- 7. During a telephone interview on [DATE] at 2:20 p.m. with the licensed practical nurse (LPN) assigned to Resident #45 on [DATE] (Employee #71) and the administrator (Employee #111), Employee #71 stated, ""Her daughter came to me and said she was acting different, and I sent her to the hospital."" Employee #71 confirmed she could not be sure she had documented any nursing assessment data on Resident #45 prior to her being sent to the hospital. .",2014-03-01
11431,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,309,G,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on family interview, closed medical record review, staff interview, and review of Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th Edition), the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for one (1) of eleven (11) sampled residents. Resident #45, who had a history of [REDACTED]. Beginning on [DATE], Resident #45 was noted to have an increased frequency in bowel elimination with three (3) BMs per shift for the next four (4) consecutive shifts; then her high frequency of BMs continued beginning on the day shift of [DATE]. Staff did not identify this increased frequency of BMs, did not describe the characteristics of these frequent BMs in the medical record (e.g., color, consistency, presence of foul or unusual odor, etc.), continued to administer her routine laxatives except when the resident refused, failed to identify a decrease in fluid intake, and failed to collect / record, monitor, and report to the physician any physical assessment data related to this resident's change in condition. All nursing documentation stopped with the last entry made at 12:05 p.m. on [DATE]. On the morning of [DATE], after intervention by the resident's legal representative, Resident #45 was transferred to the hospital due to an altered mental status and was subsequently admitted with [MEDICAL CONDITION] (C. diff.) [MEDICAL CONDITION] and proctitis; urinary tract infection [MEDICAL CONDITION]; altered mental status secondary to the above; acute hemorrhagic stroke in the parietal lobe; and dehydration. Resident #45 expired at the hospital on [DATE]. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 1. During a telephone interview beginning at 5:45 p.m. on [DATE], the daughter of Resident #45 reported that she had visited her mother at the facility and found her with a dry mouth and a foul odor associated with bowel movement and urine; according to her daughter, Resident #45 was not very responsive and could barely say her name. The daughter reported her findings to a nurse at the facility, who ""pinched"" the resident's skin and said she did not believe the resident was dehydrated. The daughter reported her belief that the facility failed to assess her mother for about one (1) week; she had visited her mother on [DATE] and ""everything was fine"", but when she returned on [DATE], she found her mother in a ""gravely ill"" condition. The daughter reported she did not hear from the facility during the period from [DATE] through [DATE] to let her know that her mother was sick. (See also citation at F157.) Her mother was not transferred to the hospital until she brought her mother's condition to the staff's attention on [DATE]. Her mother later expired at the hospital on [DATE]. -- 2. Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her nursing notes revealed the last entry was made at 12:05 p.m. on [DATE]. Further review of her record revealed a physician's telephone order dated [DATE] (no time written) to transport the resident to the local hospital's emergency room due to ""(symbol for 'change') in mental status"", although there was no corresponding entry discussing when or why this occurred. (See also citation at F514.) -- 3. Information obtained from the hospital history and physical, electronically signed by the physician on [DATE], revealed Resident #45 arrived at the emergency roiagnom on [DATE], with a chief complaint of ""altered mental status"". Under the heading ""History of Present Illness"" was found: ""This is an [AGE] year old white female who resides at Boone Nursing whose history comes from family as well as nursing staff who report (sic) that she had a (sic) altered mental status since last night. She had a decreased appetite, weakness, and diarrhea for several days. ... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..."" Under the heading ""Physical Examination"" was found: ""... Positive lethargy but no comatose state. Alert. Dehydration with dry mucous membranes. ... Bowel sounds hyperactive. ..."" Under the heading ""Labs"" was found the following abnormal values: glucose 141 (normal range = ,[DATE]); blood urea nitrogen (BUN) 58 (normal range = ,[DATE]); white blood cells 15.3 (normal range = 4XXX,[DATE]); 2+ protein in urine (normal = negative); 2+ leukocyte esterase in urine (normal = negative). Under the heading ""Assessment / Plan"" was found the following: ""1. [DIAGNOSES REDACTED] [MEDICAL CONDITIONS] and proctitis ... ""2. UTI (urinary tract infection) ... ""3. Altered mental status secondary to the above. ""4. Acute hemorrhagic stroke in parietal lobe ... ""5. Dehydration. Given light IV fluids to prevent any kind of fluid overload. ..."" -- 4. A review of the nursing notes recorded in Resident #45's medical record in the days prior to her transfer to the hospital revealed the following: - On [DATE] at 9:00 a.m. - ""N/O (new order) noted for Fleets enema per rectum x i (1) D/T (due to) (symbol for 'no') BM x 4 days. Resident tolerated procedure well /c (with) effective results noted /c med (medium) BM noted."" - On [DATE] at 11:00 a.m. - ""S/T (skin tear) to (L) (left) wrist during AM (morning) care noted. Dr. (doctor) notified /c orders for steri-strips & TAO (triple antibiotic ointment) applied. ...(Symbol for 'no') distress noted, will continue to monitor."" - On [DATE] at 12:05 p.m. - ""Resp (respirations) even & unlabored. (Symbol for 'no') SOB (shortness of breath) or cough noted. ... (Symbol for 'no') distress noted @ (at) present. Will monitor."" According to the hospital history and physical, ""... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..."" However, there was no mention in the resident's nursing notes of any decreased appetite or weakness or of the resident having had ""diarrhea for several days"" in the days preceding the resident's transfer to the hospital on [DATE]. -- 5. Review of Resident #45's nursing notes for [DATE] revealed staff called the physician and obtained an order for [REDACTED]. Review of the nursing notes for [DATE] and [DATE] found no documentation related to the resident's fluid intake and/or bowel elimination, and all nursing documentation stopped after 12:05 p.m. on [DATE]. Review of Resident #45's [DATE] ADL flow sheet revealed she had an extra large BM on the evening shift of [DATE], and then she did not have another BM until the day shift on [DATE], for which a Fleets enema was administered. According to coding on the ADL flow sheet, the resident had two (2) BMs on the day shift of [DATE]. This was followed by: - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; - Three (3) BMs on the day shift of [DATE]; - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - One (1) small BM on the night shift of [DATE]; - One (1) large BM on the day shift of [DATE]; - Two (2) large BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; and - One (1) large BM on the day shift of [DATE]. Due to an absence of nursing notes after 12:05 p.m. on [DATE], there was no evidence to reflect the licensed nursing staff collected or recorded any physical assessment data regarding the resident's overall health status, including but not limited to data regarding the resident's bowel movements (whether the stool was formed, soft, liquid, or watery and/or whether the color or odor of the stool was abnormal, etc.), the presence and quality of bowel sounds, level of consciousness, and/or hydration status. There was no evidence the licensed nursing staff identified and reported to the physician or the resident's legal representative that this resident, beginning on [DATE], was having excessively frequent BMs. -- 6. Review of the resident's medication administration records (MARs) for September and [DATE] revealed physician's orders [REDACTED]. - [MEDICATION NAME] 15 cc by mouth twice daily for constipation - Senna Plus 2 tabs by mouth twice daily for constipation - Power Pudding 60 cc at bedtime due to constipation According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE], staff continued to administer Senna Plus and [MEDICATION NAME] on [DATE] and [DATE]; the resident refused the Power Pudding. According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE] and [DATE], staff did not withhold all doses of laxatives; rather, the facility continued to administer as follows: - [DATE] - [MEDICATION NAME] at 6:00 p.m.; Senna Plus at 6:00 p.m.; Power Pudding at 9:00 p.m. - [DATE] - [MEDICATION NAME] at 10:00 a.m. and 6:00 p.m.; Senna Plus at at 10:00 a.m. and 6:00 p.m.; - [DATE] - [MEDICATION NAME] at 10:00 a.m.; Senna Plus at 10:00 a.m. (The nurses' initials were circled on the MAR for the 10:00 a.m. doses of [MEDICATION NAME] and Senna Plus on [DATE], although no explanation for this was documented on the reverse side of the MAR.) According to Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th Edition): - For [MEDICATION NAME], under ""Nursing Actions: Physical Assessment"" on page 704: ""Monitor ... therapeutic effectiveness (soft formed stools...) ... Monitor frequency / consistency of stools ..."" Under ""Nursing Actions: Patient Education"" on page 704: ""... Report persistent or severe diarrhea or abdominal cramping ..."" Under ""Geriatric Considerations"" on page 704: ""Elderly are more likely to show CNS (central nervous system) signs of dehydration and electrolyte loss. Therefore, monitor closely for fluid and electrolyte loss with chronic use...."" - For Senna Plus, under ""Nursing Actions: Patient Education"" on page 385: ""...Stop use and contact prescriber if you develop nausea, vomiting, persistent diarrhea, or abdominal cramps. ..."" -- 7. Review of the ""Shift to Shift Report"" forms dated [DATE], [DATE], and [DATE], there was no mention of the resident's increased frequency of bowel elimination, decreased intake of food or fluids, or changes in level of consciousness. The only mention of Resident #45 on these 24-hour reports was related to the skin tear on her left wrist which, according to her last nursing note, she sustained during morning care on [DATE]. -- 8. According to her [DATE] recapitulation of physician orders, Resident #45's diet order was as follows: ""LCS / NAS (low concentrated sweets / no added salt) diet w/ ground meats. Encourage fluids w/ meals."" To prevent weight loss, Resident #45's orders also included Glucerna 1 can by mouth twice daily and Med Pass 120 cc by mouth twice daily. According to her care plan, Resident #45 was ""at risk for weight loss"" related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus. Interventions for maintaining her weight at plus / minus 5# through the next review included: ""Encourage fluids with meals."" According to her weight record on [DATE], Resident #45 weighed 196# (89.1 kg). Her estimated daily fluid needs, based on a formula of 30 cc/kg, would be 2673 cc of fluid per day. Review of the ADL flow sheets for September and [DATE] revealed Resident #45 consumed less than 50% of her estimated fluid needs per day on [DATE], [DATE], and [DATE]; less than 35% of her estimated fluid needs on [DATE] and [DATE]; and she consumed on 240 cc of fluid on day shift on [DATE], prior to her transfer to the hospital. (See also citation at F327.) Review of the medical record, on [DATE] at 11:15 a.m., found no evidence to reflect the licensed nursing staff identified the resident's inadequate fluid intake and notified the physician or Resident #45's responsible party. -- 9. Resident #45 was sent out to the hospital on day shift on [DATE], but no nursing documentation was found related to assessment of the resident prior to her being sent to the hospital. According to her hospital record, she was admitted for [DIAGNOSES REDACTED], [MEDICAL CONDITION], proctitis, urinary tract infection [MEDICAL CONDITION], dehydration, leukocytosis secondary to [DIAGNOSES REDACTED] and UTI, altered mental status secondary to [DIAGNOSES REDACTED] and UTI, hypercalcemia, acute hemorrhagic stroke in the parietal lobe, and lactic acid elevation. -- 10. During a telephone interview on [DATE] at 2:20 p.m. with the licensed practical nurse (LPN) assigned to Resident #45 on [DATE] (Employee #71) and the administrator (Employee #111), Employee #71 confirmed she could not be sure she had documented any nursing assessment data on Resident #45 prior to her being sent to the hospital. Employee #71 stated, ""Her daughter came to me and said she was acting different, and I sent her to the hospital."" -- 11. In an interview on [DATE] at 10:45 a.m., the director of nursing (DON - Employee #112) confirmed she could not locate nursing documentation related to any nursing assessment of Resident #45 prior to her transfer to the hospital. ---- Part II -- Based on closed record review, the facility failed to provide daily laxatives as ordered by the physician for one (1) of eleven (11) sampled residents who was identified as being at risk for constipation. On [DATE], Resident #45 was treated for [REDACTED]. In [DATE], Resident #45 had orders for four (4) different laxatives to be administered daily: [MEDICATION NAME] 1 tab by mouth daily; Senna Plus 2 tabs by mouth twice daily; [MEDICATION NAME] 15 cc by mouth daily; and Power Pudding 60 cc by mouth at bedtime. Record review revealed found no evidence to reflect the evening dose of Senna Plus was administered as ordered; thirteen (13) doses of [MEDICATION NAME] were not administered as ordered; and fifteen (15) doses of Power Pudding were not administered as ordered, thirteen (13) of which were marked as refused by the resident. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her care plan, on [DATE], revealed the following problem statement: ""Resident is at risk for constipation: limited mobility; medications; history of constipation."" The goal associated with this problem statement was: ""Resident will have bowel movments (sic) at least every three day s (sic) thru next review."" Interventions to achieve this goal included: ""Monitor bowel movments (sic), if none in three days start bowel regimen. Monitor BM (sic) if none every 3 days notify nurse. [DATE] D/C (discontinue) [MEDICATION NAME] & [MEDICATION NAME], start Senna-S 2 tab po BID. [DATE] Power pudding 1xd (daily). ,[DATE] [MEDICATION NAME] 15 ml PO BID. [DATE] [MEDICATION NAME] 1 tab PO daily x 30 days then re-eval constipation. [DATE] leets enema per rectum x 1 dose D/T 0 (no) BM x 4 days per standing order."" - Review of Resident #45's nursing notes for [DATE] revealed staff called the physician and obtained an order for [REDACTED]. - Review of Resident #45's September Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation on the MAR indicated [REDACTED]. There was no evidence to reflect that both doses of Senna Plus were administered daily in September. - Review of the resident's [DATE] MAR indicated [REDACTED]. The nurses' initials were circled for the Power Pudding, indicating the medication was not administered as ordered, on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. There was no documentation on the reverse side of the MAR indicated [REDACTED]. (See citation at F514.) Additionally, there were no initials for the Power Pudding on [DATE] and [DATE]. This represents a total of fifteen (15) doses not administered as ordered. - Review of the resident's [DATE] MAR indicated [REDACTED]. There nurse's initials were circled for the [MEDICATION NAME], indicating the medication was not administered as ordered, on [DATE]. Documentation on the reverse side of the MAR indicated [REDACTED]."" There were no initials for the [MEDICATION NAME] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (with the last dose initialed as having been administered on [DATE]). (See also citation at F514.) This represents a total of thirteen (13) doses not administered as ordered. .",2014-03-01
11432,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,327,G,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, closed medical record review, and staff interview, the facility failed to provide the necessary care and services to ensure one (1) of eleven (11) sampled residents to maintain proper hydration and health. Resident #45 had a history of [REDACTED]. She was also identified as being at risk for weight loss related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus, and her diet order and care plan both addressed the need for staff to encourage fluid intake. On [DATE], Resident #45 received a Fleets enema on [DATE], after having no BMs for four (4) consecutive days. Beginning on [DATE], Resident #45 was noted to have an increased frequency in bowel elimination with three (3) BMs per shift for the next four (4) consecutive shifts; then her high frequency of BMs continued beginning on the day shift of [DATE]. Staff did not identify this increased frequency of BMs, continued to administer her routine laxatives except when the resident refused, and failed to collect / record, monitor, and report to the physician any physical assessment data related to this resident's change in condition. All nursing documentation stopped with the last entry made at 12:05 p.m. on [DATE]. Staff also did not identify and report to the physician a decrease in Resident #45's daily fluid intake (she was consuming less than 50% of her estimated daily fluid needs based on her weight), and although her physician orders [REDACTED]. On the morning of [DATE], after intervention by the resident's legal representative, Resident #45 was transferred to the hospital due to an altered mental status and was subsequently admitted with [MEDICAL CONDITION] (C. diff.) [MEDICAL CONDITION] and proctitis; urinary tract infection [MEDICAL CONDITION]; altered mental status secondary to the above; acute hemorrhagic stroke in the parietal lobe; and dehydration. Resident #45 expired at the hospital on [DATE]. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 1. During a telephone interview beginning at 5:45 p.m. on [DATE], the daughter of Resident #45 reported that she had visited her mother at the facility and found her with a dry mouth and a foul odor associated with bowel movement and urine; according to her daughter, Resident #45 was not very responsive and could barely say her name. The daughter reported her findings to a nurse at the facility, who ""pinched"" the resident's skin and said she did not believe the resident was dehydrated. The daughter reported her belief that the facility failed to assess her mother for about one (1) week; she had visited her mother on [DATE] and ""everything was fine"", but when she returned on [DATE], she found her mother in a ""gravely ill"" condition. The daughter reported she did not hear from the facility during the period from [DATE] through [DATE] to let her know that her mother was sick. (See also citation at F157.) Her mother was not transferred to the hospital until she brought her mother's condition to the staff's attention on [DATE]. Her mother later expired at the hospital on [DATE]. -- 2. Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her nursing notes revealed the last entry was made at 12:05 p.m. on [DATE]. Further review of her record revealed a physician's telephone order dated [DATE] (no time written) to transport the resident to the local hospital's emergency room due to ""(symbol for 'change') in mental status"", although there was no corresponding entry discussing when or why this occurred. (See also citation at F514.) -- 3. Information obtained from the hospital history and physical, electronically signed by the physician on [DATE], revealed Resident #45 arrived at the emergency roiagnom on [DATE], with a chief complaint of ""altered mental status"". Under the heading ""History of Present Illness"" was found: ""This is an [AGE] year old white female who resides at Boone Nursing whose history comes from family as well as nursing staff who report (sic) that she had a (sic) altered mental status since last night. She had a decreased appetite, weakness, and diarrhea for several days. ... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..."" Under the heading ""Physical Examination"" was found: ""... Positive lethargy but no comatose state. Alert. Dehydration with dry mucous membranes. ... Bowel sounds hyperactive. ..."" Under the heading ""Labs"" was found the following abnormal values: glucose 141 (normal range = ,[DATE]); blood urea nitrogen (BUN) 58 (normal range = ,[DATE]); white blood cells 15.3 (normal range = 4XXX,[DATE]); 2+ protein in urine (normal = negative); 2+ leukocyte esterase in urine (normal = negative). Under the heading ""Assessment / Plan"" was found the following: ""1. [DIAGNOSES REDACTED] [MEDICAL CONDITIONS] and proctitis ... ""2. UTI (urinary tract infection) ... ""3. Altered mental status secondary to the above. ""4. Acute hemorrhagic stroke in parietal lobe ... ""5. Dehydration. Given light IV fluids to prevent any kind of fluid overload. ..."" -- 4. Review of Resident #45's nursing notes for [DATE] revealed staff called the physician and obtained an order for [REDACTED]. Review of the nursing notes for [DATE] and [DATE] found no documentation related to the resident's fluid intake and/or bowel elimination, and all nursing documentation stopped after 12:05 p.m. on [DATE]. Review of Resident #45's [DATE] ADL flow sheet revealed she had an extra large BM on the evening shift of [DATE], and then she did not have another BM until the day shift on [DATE], for which a Fleets enema was administered. According to coding on the ADL flow sheet, the resident had two (2) BMs on [DATE]. This was followed nine (9) BMs on [DATE]; three (3) BMs on [DATE]; seven (7) BMs on [DATE]; six (6) BMs on [DATE]; and one (1) large BM on the day shift of [DATE]. There was no evidence the licensed nursing staff identified and reported to the physician or the resident's legal representative that this resident, beginning on [DATE], was having excessively frequent BMs. (See citation at F309.) -- 5. Review of the resident's medication administration records (MARs) for September and [DATE] revealed physician's orders [REDACTED]. - [MEDICATION NAME] 15 cc by mouth twice daily for constipation - Senna Plus 2 tabs by mouth twice daily for constipation - Power Pudding 60 cc at bedtime due to constipation According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE], staff continued to administer Senna Plus and [MEDICATION NAME] on [DATE] and [DATE]; the resident refused the Power Pudding. According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE] and [DATE], staff did not withhold all doses of laxatives; rather, the facility continued to administer them except when the resident refused. (See also citation at F309.) -- 6. Review of the ""Shift to Shift Report"" forms dated [DATE], [DATE], and [DATE], there was no mention of the resident's increased frequency of bowel elimination, decreased intake of fluids, or changes in level of consciousness. The only mention of Resident #45 on these 24-hour reports was related to the skin tear on her left wrist which, according to her last nursing note, she sustained during morning care on [DATE]. -- 7. According to her [DATE] recapitulation of physician orders, Resident #45's diet order was as follows: ""LCS / NAS (low concentrated sweets / no added salt) diet w/ ground meats. Encourage fluids w/ meals."" To prevent weight loss, Resident #45's orders also included Glucerna 1 can by mouth twice daily and Med Pass 120 cc by mouth twice daily. According to her care plan, Resident #45 was ""at risk for weight loss"" related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus. Interventions for maintaining her weight at plus / minus 5# through the next review included: ""Encourage fluids with meals."" According to her weight record on [DATE], Resident #45 weighed 196# (89.1 kg). Her estimated daily fluid needs, based on a formula of 30 cc/kg, would be 2673 cc of fluid per day. Review of the ADL flow sheets for September and [DATE] revealed Resident #45 consumed less than 50% of her estimated fluid needs per day as follows: - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 520 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1240 cc) - [DATE] - 480 cc with meals and snacks; 240 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 840 cc) - [DATE] - 360 cc with meals and snack; 480 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 960 cc) - [DATE] - ADL flow sheet documentation showed resident refused all fluids offered on day shift; 240 cc of Glucerna; 0 cc of Med Pass (total fluids on day shift prior to transfer to hospital = 240 cc) Review of the medical record, on [DATE] at 11:15 a.m., found no evidence to reflect the licensed nursing staff identified the resident's inadequate fluid intake and notified the physician or Resident #45's responsible party. -- 8. Review of Resident #45's POST form, signed by the facility's social worker on [DATE], revealed the resident's medical power of attorney representative (MPOA) had indicated, in Section D, the desire for the resident to receive IV fluids and tube feeding for a defined trial period to maintain hydration and nutritional status. There was no evidence in the medical record that staff identified a change in the resident's hydration status for which the administration of IV fluids for a trial period was indicated. -- 9. Resident #45 was sent out to the hospital on day shift on [DATE]. According to her hospital record, she was admitted for [DIAGNOSES REDACTED], [MEDICAL CONDITION], proctitis, urinary tract infection [MEDICAL CONDITION], dehydration, leukocytosis secondary to [DIAGNOSES REDACTED] and UTI, altered mental status secondary to [DIAGNOSES REDACTED] and UTI, hypercalcemia, acute hemorrhagic stroke in the parietal lobe, and lactic acid elevation. .",2014-03-01
11433,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,225,D,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of incident / accident reports, review of self-reported allegations of abuse / neglect and injuries of unknown source, and staff interview, the facility failed to immediately report and thoroughly investigate injuries of unknown source and/or an allegation of neglect involving one (1) of eleven (11) sampled residents (#23) who was totally dependent on staff for the performance of all activities of daily living (ADLs) and had limitations to range of motion and full loss of voluntary movement to both legs and feet. Record review, on 11/10/10, found a nursing note dated 10/25/10 at 11:30 a.m., stating staff identified the presence of swelling and bruising to Resident #23's left ankle and coccyx; these injuries were of unknown source. There was no evidence the facility immediately reported these injuries of unknown source to State officials as required or conducted a thorough investigation to identify possible cause(s) of the injuries and/or to ascertain whether they were the result of abuse or neglect. On 11/11/10, the facility's director of nursing (DON) produced an incident investigation report involving Resident #23, dated 10/26/10, stating staff discovered swelling and bruising to the resident's left ankle and bruising to the resident's coccyx at 11:00 a.m. on 10/26/10. Information recorded on this report suggested the bruising to the resident's ""posterior"" was the approximate size of the resident's wheelchair arm rest, and bruising may have been the result of contact between the resident and the arm rest while the resident was being transferred by mechanical lift. There was no evidence the facility immediately reported this to State officials as an allegation of neglect or made reasonable efforts to identify to which staff members may have been responsible. Resident identifier: #23. Facility census: 84. Findings include: a) Resident #23 1. Medical record review, on 11/10/10 at 9:10 a.m., disclosed the resident was admitted to the facility on [DATE]. At the time of the review, the resident's current medical [DIAGNOSES REDACTED]. The resident was determined to lack capacity to understand and make informed medical decisions for herself as early as 2003. According to information provided by facility staff, the resident did not possess the ability to participate in an interview. - Review of the resident's most recent comprehensive assessment, an annual assessment with an assessment reference date (ARD) of 01/24/10, revealed this [AGE] year old female had both short-term and long-term memory problems and her cognitive skills for daily decision-making were severely impaired. In Section G, the assessor identified that Resident #23 was non-ambulatory and totally dependent on for the performance of all ADLs, including bed mobility and transfers. Testing for sitting and standing balance could not be attempted, the resident had limitations to range of motion in both legs and feet with partial loss of voluntary movement in her lower extremities, and she was to be transferred using a mechanical lift. Review of the resident's most recent abbreviated quarterly assessment, with an ARD of 07/16/10, revealed no changes in the resident's cognitive status or ADL self-performance, and the resident was now noted to have limitations to range of motion in both legs and feet with full loss of voluntary movement in her lower extremities. - Nurse's notes, dated 10/25/10 at 11:30 a.m., revealed staff was performing ADLs for the resident ""when it was noted she had bruising to (L) (left) ankle /c (with) swelling noted & bruising to tail bone."" The resident's responsible party and attending physician were notified, and an order was received to obtain an x-ray. The x-ray report, dated 10/26/10, revealed ""no evidence for fracture or other significant bone, joint, or soft tissue abnormality."" - On 11/10/10 at 1:00 p.m., the facility's administrator (NHA - Employee #111) and director of nursing (DON - Employee #112) were interviewed regarding Resident #23's injuries identified on 10/25/10. When asked whether these injuries of unknown source were immediately reported and/or thoroughly investigated, the DON stated she did not feel the injuries were the result of abuse or that they required further investigation (even though the injuries could not have been self-inflicted, given the resident's physical limitations). This interview revealed that neither an incident report or an investigation of the injuries (which were identified on 10/25/10) could be located. There was no evidence the facility thoroughly investigated when the injuries of unknown source occurred. Additionally, there was no evidence of attempts to determine which facility staff members were present when the injuries occurred. -- 2. Prior to exit on 11/11/10 at 12:25 p.m., the DON produced an incident investigation report dated 10/26/10. Under the heading ""Describe Circumstances of the Incident (Be very specific):"" was written: ""CNA (certified nursing assistant) (first name of Employee #50) was performing ADL's on resident /c assistance of (first name of Employee #60). They noted swelling & bruising to (L) (left) ankle & bruising to tailbone."" Documentation on the report identified the ""Date of Incident"" and ""Time Incident Occurred"" as 10/26/10 at 11:00 a.m., although the nursing note first recording the discovery of these injuries was written at 11:30 a.m. on 10/25/10. Under the heading ""Witness"" were written the names of two (2) nursing assistants (Employees #50 and #60). (As noted in the description of the incident, these staff members were not reporting the incident as having occurred in their presence; rather, they were the ones who discovered the injuries.) Under the heading ""Analysis of the Incident: (apparent cause)"" was written: ""Upon investigation, noted mechanical lift used for transfers. Resident's usual w/c (wheelchair) seating has bilateral arm rests, (sic) the mechanical lift clearance observed caused resident (sic) posterior to nearly come in contact /c w/c arm rests. Bruise approx size of arm rest."" Under the heading ""Describe Corrective action (sic) or Protective Action Taken: (be specific)"" was written: ""X-ray to ankle (-) (negative). Re-educated staff on proper lift use, positioning of w/c and importance of observing clearance of resident /c chair boundaries."" - The information on this report implied that the resident's injuries found on the morning of 10/25/10 may have been the result of inappropriate and/or unsafe technique by staff while transferring the resident via mechanical lift, which would constitute an allegation of neglect. However, no statements were obtained from the individuals identified listed as witnesses to the incident, nor were statements obtained from any direct care staff that had been assigned to care for the resident during any of the shifts preceding the date and time the injuries were noted. -- 3. Review of the facility's self-reported allegations of abuse / neglect and injuries of unknown source found no evidence of any self-report to State officials involving Resident #23 for either the injuries of unknown source referenced in the resident's nursing notes at 11:30 a.m. on 10/25/10 or the injuries said to have occurred at 11:00 a.m. on 10/26/10, which were attributed to inappropriate / unsafe technique used by staff when transferring the resident via mechanical lift. .",2014-03-01
11434,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,282,D,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, policy review, and staff interview, the facility failed to ensure licensed nursing staff followed physician's orders for two (2) of eleven (11) sampled residents. For Resident #23 who wore a splinting device on her right lower extremity, the licensed nursing staff failed to collect and record physical assessment data at a frequency of every four (4) hours as orderesd by the physician. For Resident #45, there was a lack of evidence to reflect that three (3) laxatives and two (2) nutritional supplements were administered in accordance with physician's orders. Resident identifiers: #23 and #45. Facility census: 84. Findings include: a) Resident #23 Review of nursing notes, dated 11/03/10 at 1:00 p.m., revealed the resident's right leg was assessed by two (2) registered nurse (RN) supervisors. According to the notes, the resident's ""Leg and foot swollen from knee down, warm to touch. Resident /c (with) facial grimacing and yelling upon nurse touching leg."" The resident's attending physician was notified. According to the nurse's note, the resident was transferred to an area hospital to ""... R/O (rule out) [MEDICAL CONDITION] ([MEDICAL CONDITION] of R (right) LE (lower extremity)."" At 9:30 p.m. on 11/03/10, nursing notes revealed the resident had returned to the facility with a splint to the right lower leg. Review of the x-ray report, dated 11/03/10, revealed the following findings: ""A nondisplaced [MEDICAL CONDITION] fibula accompanies the distal tibia fracture. Osteopenia is apparent."" - Review of physician's orders found telephone order, dated 11/04/10 at 11:00 a.m., for: ""(1) Resident (sic) wear splint to RLE (right lower extremity) @ (at) all x's (times). (2) Resident to be monitor (sic) QS (every shift) to ensure Brace in place properly. (3) RLE to be monitored Q4(symbol for 'hour') (every four (4) hours) and documented for CRT (capillary refill time), Temp (temperature) of skin, Color of skin below splint, Pulse below splint, Presence (sic) of [MEDICAL CONDITION] Above / Below splint. (4) [MEDICATION NAME] 5/500 i (1) PO (by mouth) at 8 AM D/T (due to) pain."" - Review of the facility's policy and procedure titled ""Cast Care and Observation - Medicare Documentation Guidelines"" staff was to monitor capillary refill time, skin temperature, color of digits, ability to move digits, presence of [MEDICAL CONDITION], and for facial grimacing or other signs and symptoms of pain. According to the policy, staff was to monitor and document the findings every four (4) hours. - The first evidence of monitoring of the resident's right lower extremity, in accordance with the above noted physician's order, was found in a nursing note at 2:30 p.m. on 11/04/10. The next entry in the nursing notes containing evidence of monitoring was recorded five and one-half hours later, at 8:00 p.m. on 11/04/10. Subsequent entries containing physical assessment data of the resident's right lower extremity were recorded in the nursing notes on the following dates and times: - on 11/05/10 at 12:30 a.m. - on 11/05/10 at 2:30 p.m. - on 11/05/10 at 8:15 p.m. - on 11/06/10 at 9:00 a.m. - on 11/06/10 at 1:00 p.m. - on 11/06/10 at 5:00 p.m. - on 11/06/10 at 8:00 p.m. - on 11/07/10 at 2:20 p.m. - on 11/07/10 at 6:50 p.m. - on 11/08/10 at 12:00 a.m. (late entry) - on 11/08/10 at 4:00 a.m. (late entry) - on 11/08/10 at 11:30 a.m. - on 11/08/10 at 8:00 p.m. - on 11/09/10 at 12:00 a.m. - on 11/09/10 at 1:30 p.m. - on 11/09/10 at 4:10 p.m. - on 11/10/10 at 3:00 a.m. Review of these entries found multiple gaps between assessments of greater than four (4) hours, with one (1) gap exceeding eighteen (18) hours between consecutive entries containing physical assessment data related to the resident's right lower extremity at 8:00 p.m. on 11/06/10 and 2:20 p.m. on 11/07/10. - During the exit conference, an interview with a registered nurse (Employee #20) revealed she had written these orders to assess Resident #23's leg and document every four (4) hours ""per our policies and procedures, and they (nurses) should have been doing it."" -- b) Resident #45 Review of Resident #45's September Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation on the MAR indicated [REDACTED]. - Review of the resident's September 2010 MAR indicated [REDACTED]. The nurses' initials were circled for the Power Pudding, indicating the medication was not administered as ordered, on 09/13/10, 09/14/10, 09/15/10, 09/18/10, 09/19/10, 09/20/10, 09/24/10, 09/25/10, 09/26/10, 09/27/10, 09/28/10, 09/29/10, and 09/30/10. There was no documentation on the reverse side of the MAR indicated [REDACTED]. Additionally, there were no initials for the Power Pudding on 09/17/10 and 09/21/10. This represents a total of fifteen (15) doses not administered as ordered. - Review of the resident's September 2010 MAR indicated [REDACTED]. There nurse's initials were circled for the [MEDICATION NAME], indicating the medication was not administered as ordered, on 09/24/10. Documentation on the reverse side of the MAR indicated [REDACTED]."" There were no initials for the [MEDICATION NAME] on 09/05/10, 09/15/10, 09/16/10, 09/17/10, 09/18/10, 09/19/10, 09/20/10, 09/21/10, 09/23/10, 09/26/10, 09/27/10, and 09/28/10 (with the last dose initialed as having been administered on 09/29/10). This represents a total of thirteen (13) doses not administered as ordered. - According to the September 2010 MAR, there were orders for Glucerna 1 can PO BID and Med Pass 120 cc BID. Both of the nutritional supplements were grouped together on this MAR indicated [REDACTED]. Because these orders were not listed separately, there was no way to verify, by the nurses' initials, that both daily doses of each product were administered as ordered. (See also citations at F309, F325, and F514.) .",2014-03-01
11435,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,323,G,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of the facility's incident / accident reports, review of the facility's self-reported allegations of abuse / neglect, and staff interviews, the facility failed to provide adequate supervision and/or assistance devices to prevent avoidable accidents. One (1) of eleven (11) sampled residents (#23) was totally dependent on staff for the performance of all activities of daily living (ADLs) and had limitations to range of motion and full loss of voluntary movement to both legs and feet. On 10/26/10, she was identified as having swelling and bruising to the left ankle and coccyx; these injuries were of unknown source, although the facility's investigative report revealed the bruising on the resident's coccyx may have been associated with contact with the resident's wheelchair armrest during a transfer within a mechanical lift. On 11/03/10, the resident was identified with swelling and redness to the right leg; she was subsequently diagnosed with [REDACTED]. There was no evidence the facility implemented any measures to protect this totally dependent resident from further injury after the first injury was identified. Resident identifier: #23. Facility census: 84. Findings include: a) Resident #23 Medical record review, on 11/10/10 at 9:10 a.m., disclosed the resident was admitted to the facility on [DATE]. At the time of the review, the resident's current medical [DIAGNOSES REDACTED]. The resident was determined to lack capacity to understand and make informed medical decisions for herself as early as 2003. According to information provided by facility staff, the resident did not possess the ability to participate in an interview. -- Review of the resident's most recent comprehensive assessment, an annual assessment with an assessment reference date (ARD) of 01/24/10, revealed this [AGE] year old female had both short-term and long-term memory problems and her cognitive skills for daily decision-making were severely impaired. In Section G, the assessor identified that Resident #23 was non-ambulatory and totally dependent on for the performance of all ADLs, including bed mobility and transfers. Testing for sitting and standing balance could not be attempted, the resident had limitations to range of motion in both legs and feet with partial loss of voluntary movement in her lower extremities, and she was to be transferred using a mechanical lift. Review of the resident's most recent abbreviated quarterly assessment, with an ARD of 07/16/10, revealed no changes in the resident's cognitive status or ADL self-performance, and the resident was now noted to have limitations to range of motion in both legs and feet with full loss of voluntary movement in her lower extremities. -- Nurse's notes, dated 10/25/10 at 11:30 a.m., revealed staff was performing ADLs for the resident ""when it was noted she had bruising to (L) (left) ankle /c (with) swelling noted & bruising to tail bone."" The resident's responsible party and attending physician were notified, and an order was received to obtain an x-ray. The x-ray report, dated 10/26/10, revealed ""no evidence for fracture or other significant bone, joint, or soft tissue abnormality."" -- On 11/10/10 at 1:00 p.m., the facility's administrator (NHA - Employee #111) and director of nursing (DON - Employee #112) were interviewed regarding Resident #23's injuries identified on 10/25/10. This interview revealed that neither an incident report or an investigation of the injury of known source identified on 10/25/10 could be located. Prior to exit on 11/11/10 at 12:25 p.m., the DON produced an incident investigation report of an incident said to have occurred at 11:00 a.m. on 10/26/10. In the report under the heading ""Analysis of the Incident: (apparent cause)"" was written: ""Upon investigation, noted mechanical lift used for transfers. Resident's usual w/c (wheelchair) seating has bilateral arm rests, (sic) the mechanical lift clearance observed caused resident (sic) posterior to nearly come in contact /c w/c arm rests. Bruise approx size of arm rest."" Under the heading ""Describe Corrective action (sic) or Protective Action Taken: (be specific)"" was written: ""X-ray to ankle (-) (negative). ""Re-educated staff on proper lift use, positioning of w/c and importance of observing clearance of resident /c chair boundaries."" -- On 11/11/10 at 12:25 p.m., the DON was asked to provide evidence of the content of the staff training provided and to whom this education was provided. The DON stated this information was not available, because she ""educated the staff that were on the spot that day."" This process did not assure all staff members who might utilize the mechanical lift with this resident, on all shifts, were educated. -- Review of the facility's abuse / neglect self-reports for the previous three (3) months revealed Resident #23 had sustained another of injury of unknown source on 11/03/10. Review of nursing notes, dated 11/03/10 at 1:00 p.m. (eight (8) days after the injury of unknown source to the left leg), revealed the resident's right leg was assessed by two (2) registered nurse (RN) supervisors. According to the notes, the resident's ""Leg and foot swollen from knee down, warm to touch. Resident /c (with) facial grimacing and yelling upon nurse touching leg."" The resident's attending physician was notified. According to the nurse's note, the resident was transferred to an area hospital to ""... R/O (rule out) DVT (deep vein thrombosis) of R (right) LE (lower extremity)."" At 9:30 p.m. on 11/03/10, nursing notes revealed the resident had returned to the facility with a splint to the right lower leg. Review of the x-ray report, dated 11/03/10, revealed the following findings: ""A nondisplaced fracture of the proximal fibula accompanies the distal tibia fracture. Osteopenia is apparent."" -- Review of facility records and staff interview revealed no evidence to reflect effective measures were implemented to prevent further injury to this totally dependent resident, after the resident was found to have bruising and swelling to her left ankle and coccyx. Eight (8) days, later she sustained fractures to her right leg. .",2014-03-01
11436,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,514,E,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, closed record review, staff 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 clinical record of one (1) of eleven (11) sampled residents was maintained in accordance with accepted professional standards and practices that are complete and accurately documented. Review of the closed record of Resident #45, who was transferred to the hospital on [DATE], found incomplete and/or inaccurate documentation including but not limited to: no entries in the nursing notes describing significant changes in her health status that started on [DATE]; no entries at all after [DATE] (to include no entry related to her transfer); multiple blanks where licensed nurses were to have initialed as having administered ordered medications; multiple instances where the nurses' initials were circled (indicating medication doses were not administered) with no corresponding documentation to explain why; and documentation on the resident's [DATE] activities of daily living (ADL) flowsheet for ADL performance said to have occurred on shifts after the resident had left the faciity on [DATE]. These reflected at pattern of deficient practices affecting a single resident. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 1. No documentation related to the resident's change in condition During a telephone interview beginning at 5:45 p.m. on [DATE], the daughter of Resident #45 reported that she had visited her mother at the facility and found her with a dry mouth and a foul odor associated with bowel movement and urine; according to her daughter, Resident #45 was not very responsive and could barely say her name. The daughter reported her findings to a nurse at the facility, who ""pinched"" the resident's skin and said she did not believe the resident was dehydrated. The daughter reported her belief that the facility failed to assess her mother for about one (1) week; she had visited her mother on [DATE] and ""everything was fine"", but when she returned on [DATE], she found her mother in a ""gravely ill"" condition. The daughter reported she did not hear from the facility during the period from [DATE] through [DATE] to let her know that her mother was sick. Her mother was not transferred to the hospital until she brought her mother's condition to the staff's attention on [DATE]. Her mother later expired at the hospital on [DATE]. - Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her nursing notes revealed the last entry was made at 12:05 p.m. on [DATE]. - Information obtained from the hospital history and physical, electronically signed by the physician on [DATE], revealed Resident #45 arrived at the emergency roiagnom on [DATE], with a chief complaint of ""altered mental status"". Under the heading ""History of Present Illness"" was found: ""This is an [AGE] year old white female who resides at Boone Nursing whose history comes from family as well as nursing staff who report (sic) that she had a (sic) altered mental status since last night. She had a decreased appetite, weakness, and diarrhea for several days. ... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..."" A review of the nursing notes recorded in Resident #45's medical record in the days prior to her transfer to the hospital revealed the following: - On [DATE] at 9:00 a.m. - ""N/O (new order) noted for Fleets enema per rectum x i (1) D/T (due to) (symbol for 'no') BM x 4 days. Resident tolerated procedure well /c (with) effective results noted /c med (medium) BM noted."" - On [DATE] at 11:00 a.m. - ""S/T (skin tear) to (L) (left) wrist during AM (morning) care noted. Dr. (doctor) notified /c orders for steri-strips & TAO (triple antibiotic ointment) applied. ...(Symbol for 'no') distress noted, will continue to monitor."" - On [DATE] at 12:05 p.m. - ""Resp (respirations) even & unlabored. (Symbol for 'no') SOB (shortness of breath) or cough noted. ... (Symbol for 'no') distress noted @ (at) present. Will monitor."" However, there was no mention in the resident's nursing notes of any decreased appetite or weakness or of the resident having had ""diarrhea for several days"" in the days preceding the resident's transfer to the hospital on [DATE]. - According to Section 5.0 of the AHIMA LTC documentation guidelines: ""5.2.9 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."" ""5.2.15. Condition Changes ""Every change in a resident's condition or significant resident care issues must be noted and charted until the resident's condition is stabilized or the situation is otherwise resolved. Documentation that provides evidence of follow-through is critical."" ""5.2.18 Notification or Communications If notification to the resident's physician or family is required, or a discussion with the resident's family occurs regarding the care of the resident, all such communication (including attempts at notification) should be charted. Include the time and method of all communications or attempts. The entry should include any orders received or responses, the implementation of such orders, if any, and the resident's response. Messages left on answering machines should be limited to a request to return call and does not meet the definition of notification."" -- 2. No documentation on the date of discharge Resident #45 was sent out to the hospital on day shift on [DATE], but no nursing documentation was found related to an assessment of the resident prior to her being sent to the hospital. During a telephone interview on [DATE] at 2:20 p.m. with the licensed practical nurse (LPN) assigned to Resident #45 on [DATE] (Employee #71) and the administrator (Employee #111), Employee #71 confirmed she could not be sure she had documented any nursing assessment data on Resident #45 prior to her being sent to the hospital. Employee #71 stated, ""Her daughter came to me and said she was acting different, and I sent her to the hospital."" In an interview on [DATE] at 10:45 a.m., the director of nursing (DON - Employee #112) confirmed she could not locate nursing documentation related to any nursing assessment of Resident #45 prior to her transfer to the hospital. - According to Section 5.0 of the AHIMA LTC documentation guidelines: ""5.2.17 Admission / Discharge Notes ""The resident's initial admission note and discharge summary should fully and accurately describe the resident's condition at the time of admission and discharge, respectively. Documentation should include the method / mode of arrival / discharge, resident's response to admission / discharge and physical assessment. When discharging a resident, take special care in documenting resident education when applicable including instructions for self-care, and that the resident / responsible party demonstrated an understanding of the self-care regimen."" -- 3. ADL Flowsheet According to documentation on Resident #45's [DATE] ADL flow sheet, the nursing assistants on all three (3) shifts on [DATE] provided assistance to the resident with dressing, eating / drinking, toilet use, hygiene, and bath / shower on [DATE]. Additionally, the resident was noted to have had at least one (1) bowel movement on each shift. Resident #45 transferred to the hospital before the end of day shift on [DATE] and was not physically in the facility for either the evening or night shift on [DATE]. -- 4. Medication administration records (MARs) Review of the resident's September MAR found an order for [REDACTED]. Documentation on the MAR indicated [REDACTED]. There was no documented evidence to reflect that both doses of Senna Plus were administered daily in [DATE]. - According to the [DATE] MAR, there were orders for Glucerna 1 can PO BID and Med Pass 120 cc BID. Both of the nutritional supplements were grouped together on this MAR indicated [REDACTED]. Because these orders were not listed separately, there was no way to verify, by the nurses' initials, that both daily doses of each product were administered as ordered. - Review of the resident's [DATE] MAR indicated [REDACTED]. The nurses' initials were circled for the Power Pudding, indicating the medication was not administered as ordered, on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. There was no documentation on the reverse side of the MAR indicated [REDACTED]. Additionally, there were no initials for the Power Pudding on [DATE] and [DATE]. - According to Section 6.0 of the AHIMA LTC documentation guidelines: ""Medication and Treatment Records: ""Medication and treatment records (MARs and TARs) are derived from the physician orders [REDACTED]. ""Nurses place their initials in the blocks of the MARs and TARs form when medication or treatment has been administered. Based on physician orders, there should be no gaps noted in this documentation. ... ""Any medications or treatments given on a PRN (as needed) basis must be initialed, and information pertaining to the need for the PRN, documented either on the back of the MAR/TAR or elsewhere in the chart as defined by facility policy. Separate nurses note may also be required. ... ""Nurses will circle or otherwise indicate which medications or treatments were NOT administered. This would then require a documented explanation as to why the order could not be carried out. ...""",2014-03-01
11437,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,224,G,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, closed medical record review, staff interview, and review of Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th Edition), the facility failed to provide goods and services necessary to avoid physical harm and to maintain the highest practicable physical well-being for one (1) of eleven (11) sampled residents. Resident #45, who had a history of [REDACTED]. Beginning on [DATE], Resident #45 was noted to have an increased frequency in bowel elimination with three (3) BMs per shift for the next four (4) consecutive shifts; then her high frequency of BMs continued beginning on the day shift of [DATE]. Staff did not identify this increased frequency of BMs, did not describe the characteristics of these frequent BMs in the medical record (e.g., color, consistency, presence of foul or unusual odor, etc.), continued to administer her routine laxatives except when the resident refused, and failed to collect / record, monitor, and report to the physician and the resident's legal representative any physical assessment data related to this resident's change in condition. All nursing documentation stopped with the last entry made at 12:05 p.m. on [DATE]. Staff also did not identify and report to the physician or the resident's legal representative a decrease in Resident #45's daily fluid intake (she was consuming less than 50% of her estimated daily fluid needs based on her weight), and although her physician orders [REDACTED]. On the morning of [DATE], after intervention by the resident's legal representative, Resident #45 was transferred to the hospital due to an altered mental status and was subsequently admitted with [MEDICAL CONDITION] (C. diff.) [MEDICAL CONDITION] and proctitis; urinary tract infection [MEDICAL CONDITION]; altered mental status secondary to the above; acute hemorrhagic stroke in the parietal lobe; and dehydration. Resident #45 expired at the hospital on [DATE]. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 1. During a telephone interview beginning at 5:45 p.m. on [DATE], the daughter of Resident #45 reported that she had visited her mother at the facility and found her with a dry mouth and a foul odor associated with bowel movement and urine; according to her daughter, Resident #45 was not very responsive and could barely say her name. The daughter reported her findings to a nurse at the facility, who ""pinched"" the resident's skin and said she did not believe the resident was dehydrated. The daughter reported her belief that the facility failed to assess her mother for about one (1) week; she had visited her mother on [DATE] and ""everything was fine"", but when she returned on [DATE], she found her mother in a ""gravely ill"" condition. The daughter reported she did not hear from the facility during the period from [DATE] through [DATE] to let her know that her mother was sick. (See also citation at F157.) Her mother was not transferred to the hospital until she brought her mother's condition to the staff's attention on [DATE]. Her mother later expired at the hospital on [DATE]. -- 2. Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her nursing notes revealed the last entry was made at 12:05 p.m. on [DATE]. Further review of her record revealed a physician's telephone order dated [DATE] (no time written) to transport the resident to the local hospital's emergency room due to ""(symbol for 'change') in mental status"", although there was no corresponding entry discussing when or why this occurred. (See also citation at F514.) -- 3. Information obtained from the hospital history and physical, electronically signed by the physician on [DATE], revealed Resident #45 arrived at the emergency roiagnom on [DATE], with a chief complaint of ""altered mental status"". Under the heading ""History of Present Illness"" was found: ""This is an [AGE] year old white female who resides at Boone Nursing whose history comes from family as well as nursing staff who report (sic) that she had a (sic) altered mental status since last night. She had a decreased appetite, weakness, and diarrhea for several days. ... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..."" Under the heading ""Physical Examination"" was found: ""... Positive lethargy but no comatose state. Alert. Dehydration with dry mucous membranes. ... Bowel sounds hyperactive. ..."" Under the heading ""Labs"" was found the following abnormal values: glucose 141 (normal range = ,[DATE]); blood urea nitrogen (BUN) 58 (normal range = ,[DATE]); white blood cells 15.3 (normal range = 4XXX,[DATE]); 2+ protein in urine (normal = negative); 2+ leukocyte esterase in urine (normal = negative). Under the heading ""Assessment / Plan"" was found the following: ""1. [DIAGNOSES REDACTED] [MEDICAL CONDITIONS] and proctitis ... ""2. UTI (urinary tract infection) ... ""3. Altered mental status secondary to the above. ""4. Acute hemorrhagic stroke in parietal lobe ... ""5. Dehydration. Given light IV fluids to prevent any kind of fluid overload. ..."" -- 4. A review of the nursing notes recorded in Resident #45's medical record in the days prior to her transfer to the hospital revealed the following: - On [DATE] at 9:00 a.m. - ""N/O (new order) noted for Fleets enema per rectum x i (1) D/T (due to) (symbol for 'no') BM x 4 days. Resident tolerated procedure well /c (with) effective results noted /c med (medium) BM noted."" - On [DATE] at 11:00 a.m. - ""S/T (skin tear) to (L) (left) wrist during AM (morning) care noted. Dr. (doctor) notified /c orders for steri-strips & TAO (triple antibiotic ointment) applied. ...(Symbol for 'no') distress noted, will continue to monitor."" - On [DATE] at 12:05 p.m. - ""Resp (respirations) even & unlabored. (Symbol for 'no') SOB (shortness of breath) or cough noted. ... (Symbol for 'no') distress noted @ (at) present. Will monitor."" According to the hospital history and physical, ""... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..."" However, there was no mention in the resident's nursing notes of any decreased appetite or weakness or of the resident having had ""diarrhea for several days"" in the days preceding the resident's transfer to the hospital on [DATE]. -- 5. Review of Resident #45's nursing notes for [DATE] revealed staff called the physician and obtained an order for [REDACTED]. Review of the nursing notes for [DATE] and [DATE] found no documentation related to the resident's fluid intake and/or bowel elimination, and all nursing documentation stopped after 12:05 p.m. on [DATE]. Review of Resident #45's [DATE] ADL flow sheet revealed she had an extra large BM on the evening shift of [DATE], and then she did not have another BM until the day shift on [DATE], for which a Fleets enema was administered. According to coding on the ADL flow sheet, the resident had two (2) BMs on the day shift of [DATE]. This was followed by: - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; - Three (3) BMs on the day shift of [DATE]; - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - One (1) small BM on the night shift of [DATE]; - One (1) large BM on the day shift of [DATE]; - Two (2) large BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; and - One (1) large BM on the day shift of [DATE]. Due to an absence of nursing notes after 12:05 p.m. on [DATE], there was no evidence to reflect the licensed nursing staff collected or recorded any physical assessment data regarding the resident's overall health status, including but not limited to data regarding the resident's bowel movements (whether the stool was formed, soft, liquid, or watery and/or whether the color or odor of the stool was abnormal, etc.), the presence and quality of bowel sounds, level of consciousness, and/or hydration status. There was no evidence the licensed nursing staff identified and reported to the physician that this resident, beginning on [DATE], was having excessively frequent BMs. (See also citation at F309.) -- 6. Review of the resident's medication administration records (MARs) for September and [DATE] revealed physician's orders [REDACTED]. - [MEDICATION NAME] 15 cc by mouth twice daily for constipation - Senna Plus 2 tabs by mouth twice daily for constipation - Power Pudding 60 cc at bedtime due to constipation According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE], staff continued to administer Senna Plus and [MEDICATION NAME] on [DATE] and [DATE]; the resident refused the Power Pudding. According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE] and [DATE], staff did not withhold all doses of laxatives; rather, the facility continued to administer as follows: - [DATE] - [MEDICATION NAME] at 6:00 p.m.; Senna Plus at 6:00 p.m.; Power Pudding at 9:00 p.m. - [DATE] - [MEDICATION NAME] at 10:00 a.m. and 6:00 p.m.; Senna Plus at at 10:00 a.m. and 6:00 p.m.; - [DATE] - [MEDICATION NAME] at 10:00 a.m.; Senna Plus at 10:00 a.m. (The nurses' initials were circled on the MAR for the 10:00 a.m. doses of [MEDICATION NAME] and Senna Plus on [DATE], although no explanation for this was documented on the reverse side of the MAR.) According to Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th Edition): - For [MEDICATION NAME], under ""Nursing Actions: Physical Assessment"" on page 704: ""Monitor ... therapeutic effectiveness (soft formed stools...) ... Monitor frequency / consistency of stools ..."" Under ""Nursing Actions: Patient Education"" on page 704: ""... Report persistent or severe diarrhea or abdominal cramping ..."" Under ""Geriatric Considerations"" on page 704: ""Elderly are more likely to show CNS (central nervous system) signs of dehydration and electrolyte loss. Therefore, monitor closely for fluid and electrolyte loss with chronic use...."" - For Senna Plus, under ""Nursing Actions: Patient Education"" on page 385: ""... Stop use and contact prescriber if you develop nausea, vomiting, persistent diarrhea, or abdominal cramps. ..."" (See also citation at F309.) -- 7. Review of the ""Shift to Shift Report"" forms dated [DATE], [DATE], and [DATE], there was no mention of the resident's increased frequency of bowel elimination, decreased intake of food or fluids, or changes in level of consciousness. The only mention of Resident #45 on these 24-hour reports was related to the skin tear on her left wrist which, according to her last nursing note, she sustained during morning care on [DATE]. -- 8. According to her [DATE] recapitulation of physician orders, Resident #45's diet order was as follows: ""LCS / NAS (low concentrated sweets / no added salt) diet w/ ground meats. Encourage fluids w/ meals."" To prevent weight loss, Resident #45's orders also included Glucerna 1 can by mouth twice daily and Med Pass 120 cc by mouth twice daily. According to her care plan, Resident #45 was ""at risk for weight loss"" related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus. Interventions for maintaining her weight at plus / minus 5# through the next review included: ""Encourage fluids with meals."" According to her weight record on [DATE], Resident #45 weighed 196# (89.1 kg). Her estimated daily fluid needs, based on a formula of 30 cc/kg, would be 2673 cc of fluid per day. Review of the ADL flow sheets for September and [DATE] revealed Resident #45 consumed 600 cc or less per day as follows: - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 520 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1240 cc) - [DATE] - 480 cc with meals and snacks; 240 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 840 cc) - [DATE] - 360 cc with meals and snack; 480 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 960 cc) - [DATE] - ADL flow sheet documentation showed resident refused all fluids offered on day shift; 240 cc of Glucerna; 0 cc of Med Pass (total fluids on day shift prior to transfer to hospital = 240 cc) Review of the medical record, on [DATE] at 11:15 a.m., found no evidence to reflect the licensed nursing staff identified the resident's inadequate fluid intake and notified the physician or Resident #45's responsible party. (See also citation at F327.) -- 9. Resident #45 was sent out to the hospital on day shift on [DATE], but no nursing documentation was found related to assessment of the resident prior to her being sent to the hospital. According to her hospital record, she was admitted for [DIAGNOSES REDACTED], [MEDICAL CONDITION], proctitis, urinary tract infection [MEDICAL CONDITION], dehydration, leukocytosis secondary to [DIAGNOSES REDACTED] and UTI, altered mental status secondary to [DIAGNOSES REDACTED] and UTI, hypercalcemia, acute hemorrhagic stroke in the parietal lobe, and lactic acid elevation. -- 10. During a telephone interview on [DATE] at 2:20 p.m. with the licensed practical nurse (LPN) assigned to Resident #45 on [DATE] (Employee #71) and the administrator (Employee #111), Employee #71 confirmed she could not be sure she had documented any nursing assessment data on Resident #45 prior to her being sent to the hospital. Employee #71 stated, ""Her daughter came to me and said she was acting different, and I sent her to the hospital."" -- 11. In an interview on [DATE] at 10:45 a.m., the director of nursing (DON - Employee #112) confirmed she could not locate nursing documentation related to any nursing assessment of Resident #45 prior to her transfer to the hospital. .",2014-03-01
11438,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,325,D,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, the facility failed to ensure one (1) of eleven (11) residents, who was identified as being at risk for weight loss, received nutritional supplements in accordance with physician orders. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. According to her October 2010 recapitulation of physician orders, Resident #45's diet order was as follows: ""LCS / NAS (low concentrated sweets / no added salt) diet w/ ground meats. Encourage fluids w/ meals."" To prevent weight loss, Resident #45's orders also included Glucerna 1 can by mouth twice daily and Med Pass 120 cc by mouth twice daily. According to her care plan, Resident #45 was ""at risk for weight loss"" related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus. Interventions for maintaining her weight at plus / minus 5# through the next review included: ""... Med pass (sic) 120cc (sic) bid. Glucerna 1 can po bid for supplement."" According to the September 2010 MAR, there were orders for Glucerna 1 can PO BID and Med Pass 120 cc BID. Both of the nutritional supplements were grouped together on this MAR indicated [REDACTED]. Because these orders were not listed separately, there was no way to verify, by the nurses' initials, that both daily doses of each product were administered as ordered. (See also citation at F514.) .",2014-03-01
11439,GOLDEN LIVINGCENTER - GLASGOW,515118,PO BOX 350,GLASGOW,WV,25086,2010-11-17,159,D,,,TT3W11,". Based on a review of personal funds of residents deposited with the facility, facility policies for Resident Trust Fund / Valuables (revised 08/03/09), and staff interviews, the facility failed to obtain written authorization to manage personal funds for two (2) of eight (8) sampled residents (#91 and #90) who had personal funds deposited with the facility. Facility census: 89. Findings include: a) Resident #91 Review of facility records, with the business office manager (BOM - Employee #29), on the mid-morning of 11/17/10, found a Resident Fund Management Service Authorization and Agreement to Handle Resident Funds form for Resident #91 dated 04/07/10; this authorization form found was signed by a person who was designated by the resident to serve as medical power of attorney representative (MPOA) only. The resident's financial file did not include any information regarding the authority of this person to make financial decisions for the resident. The BOM reported the resident was unable to sign for herself and acknowledged the resident's MPOA did not have the authority to sign the document. -- b) Resident #90 Review of facility records, with the Employee #29, on the mid-morning of 11/17/10, found a Resident Fund Management Service Authorization and Agreement to Handle Resident Funds form for Resident #90 dated 02/10/10; this authorization form found was signed by a person who was designated by the resident to serve as MPOA only. The resident's financial file did not include any information regarding the authority of this person to make financial decisions for the resident. The BOM reported the resident was unable to sign for herself and acknowledged the resident's MPOA did not have the authority to sign the document. -- c) Review of the Resident Trust Fund / Valuables facility policy (revised 08/03/09), under ""Authorization to Manage Funds"", found: ""Every resident has the right to manage his/her funds. If the resident chooses to have the facility set up a trust fund in his/her name, the resident, agent, or legal representative must authorize the facility to do so by signing the Resident Trust Fund Authorization form. By signing the form, the resident authorizes the facility to hold the resident's fund in a qualified Resident Trust Account....""",2014-03-01
11440,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2010-11-18,323,G,,,65CW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide adequate supervision and/or assistive devices for one (1) of five (5) residents reviewed to prevent avoidable accidents. Resident #89, who had experienced a decline in physical condition and was diagnosed with [REDACTED]. There was no evidence the facility evaluated the resident's ability to be unsupervised in the wheelchair due to her condition at 9:00 a.m., her weakened condition due to pneumonia, and her potential weakness as the result of refusing both meals prior to the fall. The resident was not assessed to determine whether supervision to avoid an accident was necessary. The facility had not evaluated the risk of this resident having an avoidable accident or implemented any interventions to reduce the risk of a fall. Later that day, the resident was gotten out of bed and placed in a wheelchair so an air mattress could be placed on the bed. She was unsupervised in the wheelchair and was found on the floor at 4:23 p.m. on 10/13/10. She sustained injuries and required hospitalization . There was no evidence that staff, who placed her in the wheelchair, had been made aware the resident was put to bed earlier in the day because she was leaning forward in her wheelchair. Subsequently, the resident experienced a fall from the wheelchair with injuries. Resident identifier: #89. Facility census: 88. Findings include: a) Resident #89 When reviewed on 11/17/10 and 11/18/10, the medical record of Resident #89 disclosed this [AGE] year old female had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. - On 10/13/10 at 9:00 a.m., a nursing note stated, ""Resident up in w/c (wheelchair) with 1 person assist leaning (sic) forward in w/c assisted resident back to bed."" A nursing note, dated 10/13/10 at 9:31 a.m., stated, ""Resident's daughter was upset over finding her mother slumped in her bed ...Resident has shown a steady decline over last several months. Oral intake is poor. Resident refuses to be fed."" A nursing note entry dated 10/13/2010 at 15:57 (3:57 p.m.) described that the resident was propelling herself in the wheelchair, and was found in the floor. Further review of the medical record revealed no interventions relative to safety and/or to prevent further falls. An additional nursing note, on 10/13/10 at 16:23 (4:23 p.m.), stated, ""Notified by staff that resident was found in the floor. Resident had been gotten out of bed to place air mattress on bed. Resident had been wheeling self about facility and then was found in the floor on A hall. Resident was found face down with a laceration to the R (right) eyebrow and cheek. Complained of pain to R hip."" The resident was transported to an area hospital. The medical record described the residents weakened Physical condition and continued decline. Documentation in the resident's medical record described a slow decline in her physical condition from the time of admission. The resident had acquired Clostridium difficile (C. diff - a condition that results in frequent diarrhea) after admission to the facility on [DATE] and, following treatment, had a negative stool culture on 10/05/10. The resident was diagnosed with [REDACTED]. The resident's oral intake was minimal from the time of admission. The resident's weight record stated an admission weight of 139.5# on 07/28/10 and a weight of 131# on 10/06/10. On 08/06/10, the resident was placed on the medication Megace to increase her appetite, and it was discontinued on 10/01/10. Meal intake reviews showed that, shortly before her hospitalization on [DATE], the resident's meal intake ranged from 0% (refusal) to 50%. The resident refused both meals prior to her fall and hospitalization on [DATE]. - A facility's occupational therapist (OT - Employee #3), who had worked with Resident #89 until shortly before her fall with injury, was interviewed at 10:30 a.m. on 10/18/10. When asked about her experiences with the resident and the resident's condition, the OT stated the resident had had a slow decline in her condition almost from the time of admission and, in the last few days prior to discontinuation of services, the resident had been less responsive and unable to follow direction. A nursing note, dated 10/06/10, stated, ""Resident to be discharged from therapy services today."" - The facility's director of nurses (DON), when interviewed on 11/18/10 concerning the resident's fall, stated she was fully aware of the resident's decline in several areas, to include her bout of [DIAGNOSES REDACTED], poor appetite and meal refusals, weight loss, and pneumonia, but that the resident had remained able to sit upright in her wheelchair. The DON did not know if facility staff who placed her in the wheelchair were aware the resident had been unable to sit up earlier in the day. The DON further confirmed the resident had not been re-evaluated for her ability to be independent in her wheelchair as her condition declined.",2014-03-01
11441,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2011-01-25,309,G,,,65CW12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of medical records (both electronic and paper), staff interviews, review of in-service records, review of disciplinary action documents, review of controlled substances records, review of the facility's documentation regarding falls, review of the facility's investigations of falls and reportable events, and observations, the facility had failed to ensure a resident received appropriate and timely interventions for management of the onset of pain. The lack of pain management constituted actual harm to the resident. Review of documentation found a resident had sustained falls in December 2010. The last fall was noted to have occurred on 12/25/10. She later began to demonstrate both verbal and non-verbal indicators of pain. During this time, she also began to exhibit a limp and a decreased effort to ambulate. The onset of pain symptoms was evident beginning on the late morning of 12/31/10. A total of six (6) doses of Tylenol 650 mg were documented as given. The effectiveness of those doses was not documented (or documented in the negative), and documentation indicated the resident's pain symptoms persisted. The physician saw the resident in the afternoon on 12/31/10. He noted the resident was crying but did not order any additional pain medication. There was no evidence further treatment of [REDACTED]. On 01/02/11 at 23:39 (11:39 p.m.), the resident was sent to the hospital where it was found she had a [MEDICAL CONDITION]. Through review of medical records, review of the controlled substances sign-out book for Mary's Garden, staff interviews, observations, and review of documentation of in-services and disciplinary actions, it was determined the facility had identified and addressed the deficits in the provision of care related to pain management for Resident #50. This deficient practice was determined to constitute past noncompliance as it occurred after the last standard survey (completed on 09/25/09) and before the start of this on-site revisit to a complaint investigation on 01/24/11. Resident identifier: #50. Facility census: 84. Findings include: a) Resident #50 During review of occurrences reported to the State in accordance with the ?483.13(c)(1)(ii), it was noted a report had been completed for Resident #50 on 01/03/11. The report indicated the resident had an injury of unknown source. She had been sent to the emergency room for complaints of pain, where she was found to have a displaced [MEDICAL CONDITION] hip. Record review revealed this [AGE] year old female resident had [DIAGNOSES REDACTED]., and dementia with behavioral disturbances. -- 1. Review of the nursing entries and assessments found she had fallen on 12/09/10. A nursing entry for 12/09/10 at 18:09 (6:09 p.m.), by Employee #111 (a licensed practical nurse (LPN)) noted the resident had fallen in the last 72-hours. She had experienced a witnessed fall at the nurses' station. At that time, the resident was not exhibiting signs and symptoms of pain according to the nurse. A late entry on 12/10/10 at 2:09 (the author did not indicate the date or time of the original event for which this late entry was made), made by an LPN, noted the resident was ambulatory for short distances that morning. She was also noted to be unsteady of gait at times. On 12/12/10 at 13:14 (1:14 p.m.), Employee #29 (an LPN) noted the resident had fallen. The resident had been ambulating in the common area of the unit. The nurse wrote (excerpts typed as written), ""... (Resident's name) is experiencing pain. right hip sore-per resident. ..."" On 12/12/10 at 21:14 (9:14 p.m.), Employee #29 wrote the resident was resting in bed at that time. The note included (excerpts typed as written), ""Cont(inue) to monitor for bruising/ c/o's (complaints of) pain."" On 12/13/10 at 10:29 (8:29 p.m.), Employee #29 noted the resident was sitting in the common area with other residents. It was also noted, ""Ambulating slow-gait steady at this time."" The next nursing entry was at 19:57 (7:57 p.m.) on 12/19/10 by Employee #29. The resident was note to be ambulating in the common area. She refused to sit down or use a wheelchair. Her gait was noted to be unsteady. On 12/22/10 at 4:38 (4:38 a.m.), Employee #64 (an LPN) noted by that a body audit had been completed with no new areas found. On 12/27/10 at 16:12 (4:12 p.m.), Employee #29 noted the resident was ambulating with an unsteady gait. It was also noted staff had assisted the resident with ambulating several times that day. The nurse wrote (excerpts typed as written), ""Res(ident) will sit for a few min's (minutes) then gets up and ambulates."" On 12/29/10 at 10:17 (10:17 a.m.), Employee #49 (the director of nursing (DON)), spoke with the resident's son about the resident's lethargy and falls risk. The son stated he would rather not have a lap buddy or seat belt used at that time. Her medications were also discussed with the son - that [MEDICATION NAME] had been discontinued due to the possible side effect of muscle spasms. The psychologist had changed the resident's medication to [MEDICATION NAME], and she appeared to be a little more lethargic. Dosage reduction was to be discussed with a psychiatrist. The next entry was at 15:33 (3:33 p.m.) on 12/31/10 by Employee #113 (an LPN), who wrote (excerpts typed as written), ""Res c\o severe pain to R(ight) leg\knee. Visible signs of pain present: teary eyes, moaning\guarding area with movement. This nurse administered Tylenol per standing order. RN supervisor notified and assessed area. Dr. (name) present new orders received for X-ray to R knee and R femur. (X-ray supplier) notified and X-rays ordered STAT (immediately)."" On 12/31/10 at 16:33 (4:33 p.m.), it was noted the x-rays had been completed. On 12/31/10 at 22:24 (10:24 p.m.), Employee #64 (an LPN), wrote (excerpts typed as written), ""Res c\o severe pain to R leg\knee. Visible signs of pain present: teary eyes, moaning \ guarding area with movement. This nurse administered Tylenol per standing order. X-ray result from (x-ray supplier) are unremarkable. Dr. (name) notified."" On 01/01/11 at 04:54 (4:54 a.m.), Employee #113 (an LPN) wrote (excerpts typed as written), "" Resident continues to complain of severe R knee and leg pain. Tylenol given per standing order. Will continue to monitor."" On 01/01/11 at 09:33 (9:30 a.m.), Employee #113 noted (excerpts typed as written), ""Res cont to c\o pain to R knee \ leg. Tylenol per standing order administered at this time."" On 01/02/11 at 06:32 (6:32 a.m.), Employee #114 wrote (excerpts typed as written), ""Res had c/o pain upon waking this am. Tylenol gave at 6am. Will cont to monitor."" In the next entry, at 18:54 (6:54 p.m.) on 01/02/11, Employee #111 (an LPN) wrote (excerpts typed as written), ""Resident had continued throughout the day to exhibit s/sx (signs/symptoms) of pain ( facial grimace, moaning, tears) and grabs at right hip when staff attempt to help reposition her. Resident denies pain and states she doesn't know what to do, as explaination as to why she was crying. Spoke with Dr. (name) who ordered STAT xrays of her right pelvis and right hip. [MEDICATION NAME] 5/500mg one by mouth every four hours as needed. Dr. (name) to call in the medication to the pharmacy, have contacted (x-ray supplier) for STAT x-rays. Son, (son's name) notified of n/o's (new orders). ..."" The x-rays were noted to have been completed at 21:17 (9:17 p.m.) on 01/02/11. At 23:39 (11:39 p.m.) on 01/02/11, Employee #111 noted the x-ray had shown a ""right displace [MEDICAL CONDITION]."" She wrote the resident was transferred to the hospital for evaluation and treatment. -- 2. Review of the statements taken during the facility's investigation of the resident's fracture (written as faithfully to the original as possible, with the statements of some individuals having been broken into segments in order to place them in chronological order) found the following: 12/25/10 - Employee #99 (a nursing assistant - NA) - ""... Resident was lethargic mood, resident when gotten up in wheel chair, attempted getting up and walking. When she did attempt to walk had a limp on right side, didn't seem to be in pain. Resident wasn't on feet for any length of time because of possible falling on X-mas day. Resident seemed very lethargic for several days, wouldn't hardly eat or drink. Resident seemed to want to sleep a lot... I worked on 12/25/26/28/29/30/31/1 On these days (Resident's name) got out of bed most days between 9 A and 11 A then on Fri, 31st she slept later than usual when resident finally got out of bed she states she was hurting on right side & started crying."" 12/31/10, night shift - Employee #105 (NA) - ""(Resident's name) was lying in bed awake all night. My self and nurse kept going in there to check on her. When straightened up in bed, resident would turn back to her one side facing the door. The nurse asked her if she was in pain, resident stated that it was never ending. ..."" 12/31/10, days / evenings - Employee #113 (LPN) - This nurse noted the resident had slept later than usual. ""... the CNA's reported to me the pt was in pain when they brought her into the common's area. Upon assessment, pt had visible s/s of pain. She was holding her right knee, had tears in her eyes and was shaking. I administered Tylenol per physician's standing order. I then call Rehab unit for an RN to come over and assess pt. (Employee #60), RN assess pt. right leg and knee. She stated she would ask Dr. (name) to come over since he was in the building. Dr. (name) came over about 20-30 mins later and examined pt. He ordered a STAT x-ray of right knee and femur. ... completed x-ray around 4:30 p.m. ..."" 12/31/10, day shift - Employee #26 (NA) - ""On Friday 12-31-10 on 2:00 p rounds (Resident's name) was still in bed. Another aid & I got her up. She would not put any weight on her (R) side. She was tearful and complained of pain while holding her (R) knee. I asked her where she was hurting & she said everywhere. ..."" 01/01/11, night shift - Employee #20 (LPN) - This nurse noted the evening shift nurse had told her the resident had been complaining of pain and she had been given Tylenol. ""...was in the bed, she was restless during the night but did not attempt to get out of bed. Around 6am this nurse and CNA (Employee 37) went in to do last round on resident. After she woke up she had a grimace on her face. I asked resident if she was in pain and she said 'yes.' We asked her to show us where she was hurting and resident stated 'All over.' I lifted residents R Leg to put on a sock and resident grabed her R side. I went and got resident some Tynenol per standing order . . . I asked the oncoming nurse if she could try to get (Resident's name) something stronger for pain and I told her how she had grabed at her R side when I lifted her leg."" 01/01/11, day shift - Employee #26 (NA) - ""On Saturday 1-1-11 she complained of being in pain all day & refused to eat. . . ."" 01/01/11, days / evenings - Employee #113 (LPN) - ""... Tylenol administered at 9:30am with am meds. Pt was holding her right knee and had tears in her eyes. ..."" 01/01/11, evenings / nights - Employee #37 (NA) - ""... At around 4 pm I helped take her to the bathroom, it took two of us because She was telling us the She couldn't stand because She was hurting. I asked what was hurting her and She said 'I'm hurting all over' . She was like that for most of the rest of the shift, tearful and had a pained look on her face... She was up most of the night on the 11-7 shift. She never tried to get out of bed, but She was restless and saying she was hurting. At around six Sunday morning, (Employee #20), LPN & I went in to do our last round and She had finally went to sleep, upon checking her for incontinence she woke up and I asked her if she was still hurting and she said she was. When (Employee #20) picked up her right foot to put her sock on, she grabbed her right leg and grimaced. We asked her where she was hurting and again She said 'All over'. We checked her all over real good while dressing her and found no abrasions or bruised other than two small faint ones on her right buttocks... (Employee #20) gave her some Tylenol. While sitting there, she fell back asleep but still had a pained look on her face. ... "" 01/01/11 - Employee #32 - ""On Jan. 1 & 2, I noticed that (Resident's name) was in intense pain. She was crying about her hip. Staff was aware of this. (Resident's name) did not stand and was watched closely watched in her wheelchair. On December 30, (Resident's name) was up in her wheelchair & made no attempts to get up that day."" 01/01/11 - Employee #104 (NA) - ""... was in bed complaining of leg pain, after, getting up she complained more to the point of not eating and crying. ..."" Employee #104 also noted the resident could not stand on her leg. 01/02/11 - Employee #32 - ""On Jan. 1 & 2, I noticed that (Resident's name) was in intense pain. She was crying about her hip. Staff was aware of this. ..."" 01/02/11, day shift, Employee #26 (NA) - ""... On Sunday 1-2-11 she still complained of being in pain all day long."" 01/02/11 - Employee #104 (NA) - ""... Cryed in bed and after getting in wheelchair. She was so miserable and crying in pain we put her in the recliner in the common area. She could not stand on her leg either day."" 01/02/11 - days / evenings, Employee #111 (LPN) - ""... Resident slept until right before lunch in the recliner chair. When (Resident's name) woke up, she was tearful, but when I asked her if she was hurting, she said 'no'. I asked her in several different ways if she was hurting, but she kept denying pain and stated, 'I just don't know where I am or what I'm supposed to do.' ... Throughout the shift, I administered Tylenol to (Resident) as ordered just to be sure that she wasn't experiencing pain. The Tylenol did not affect her tearfulness."" She also noted she had tried to contact Dr. (name) at 1400 (2:00 p.m.), but contact was not made until 1830 (6:30 p.m.) She told him about the resident's ""persistent tearfulness and guarding when awake. ..."" An x-ray was ordered and at approximately 2330 (11:30 p.m.) received x-ray reports that the resident had a displaced [MEDICAL CONDITION] hip, and she was transferred to the hospital. 01/02/11, evenings / nights - Employee #37 - ""I came back on at 3pm, (Resident's name) was asleep in beige recliner. She slept most of the evening but kept her hand on her right leg. She was gotten up and toileted before dinner, took 2 of us just like the night before. She ate (was fed) very little dinner saying she was tired of hurting and had tears in her eyes. This aide did not put her to bed but as I was putting her roommate to bed, she was lying in bed and crying, saying, 'I can't take this pain anymore'. After finishing with her roommate, I checked on her, tried to reposition her to make her a little more comfortable but nothing really helped. After that we kept making 15 min - ? hr checks on her until she was sent out."" 01/02/11, night shift - Employee #20 (LPN) - ""I came back in Sun night (1-2-11) for 11-7 shift. The nurse (nurse's name) that worked that day + evening gave report on (Resident's name). She said that she had got a order for [MEDICATION NAME]. I received a phone call about the x-rays and that (Resident's name) (R) hip was broken. ..."" The resident was sent out to the hospital. -- 3. The physician's progress note for 12/31/10 included, ""C/O pain (R) thigh & knee area. (Symbol of 'no') knee swelling. Able to extend knee. No perceptible tenderness but the pain is really hurting her/c crying, etc."" -- 4. Review of the medication administration records found she had been given Tylenol, according to the front sheet of the medication administration records (MAR) as follows: on 12/31/10 at 2:00 p.m. and 9:00 p.m.; on 01/01/11 at 3:30 a.m., 9:30 a.m., and 5:00 p.m.; and on 01/02/11 at 6:00 a.m., 9:00 a.m., and 3:00 p.m. This was a total of eight (8) doses. - The back of the MARs indicated the resident received Tylenol for pain as follows: On 12/31/10: - At 2:00 p.m. for ""C/O pain (R) knee/leg"", with no results documented - At 9:00 p.m. for ""C/O pain (R) knee/leg"", with the results charted as ""(-)"" (a minus sign that was circled) On 01/01/11: - At 3:30 a.m. for ""C/O (R) knee & leg pain, with the results charted as ""(-)"" - At 9:30 a.m. for ""C/O (R) leg/knee pain"", with no results charted - At 5:00 p.m. for ""C/O (R) leg/knee pain"", with no results charted On 01/02/11: - At 6:00 a.m. for ""C/O (R) leg pain"", with the results charted as ""(-)"" This was a total of six (6) doses. - On 01/24/11 at 6:05 p.m., Employee #29 (LPN) was asked about the minus signs. She said, ""If you don't get a plus you need to do something else."" Review of the nursing entries and MARs, regarding the administration of Tylenol, found it was given regardless of the severity of the pain. The pain was not rated consistently, and there were only three (3) of eight (8) doses that had been evaluated for effectiveness. The physician's orders [REDACTED]."" However, it was not noted the resident complained of a headache during this time. Tylenol is for mild to moderate pain. Although the resident was noted to have severe pain at times, there was no evidence staff contacted the physician for an [MEDICATION NAME] that would control the resident's pain. According to the controlled medication book, the [MEDICATION NAME] had arrived at 11:00 p.m. on 01/02/11. No doses were signed out in the book, nor charted on the Medication Administration Record, [REDACTED] -- b) Evidence of the facility's identification and correction of the deficient practice related to pain management 1. On 01/24/11 at approximately 6:15 p.m., the director of nursing (DON) provided copies of two (2) ""One on One Education"" forms. One (1), date 01/07/11, was for Employee #56 (an RN). The concern was ""not adequately assessing resident for pain or pain relief. Pain assessment and change of condition not initiated /c (with) new onset of pain."" The corrective action needed to remedy concerns: ""Must ensure that all resident are as free of pain as possible. Must complete pain assessment & change of condition /c any new onset of pain. Must notify physician of resident need and obtain adequate medication."" Another education form was completed on 01/07/11 for Employee #113 (an LPN). It had essentially the same information as the other. As the DON pointed out, the RN was responsible for assessing resident and the LPN was responsible for evaluation of the resident. The DON said another form had been completed for another nurse, but she was unable to locate that document prior to exit. -- 2. The DON also provided a copy of an in-service on ""Pain Management"" that had been provided to staff. This addressed evaluation of pain, notification of the physician, continued assessment of the resident for the presence of pain - either verbal or observation of non-verbal indicators, documentation of evaluations, care planning, assessment and documentation of the effectiveness of pain interventions, notification of the physician when pain medications were ineffective, and so on. -- 3. The administration of pain medications to Resident #50 after her return from the hospital was reviewed. Page 204 of the ""Controlled Substances Book"" indicated she received [MEDICATION NAME] 5/500 at 9:00 p.m. on 01/13/11. She received a total of three (3) doses of [MEDICATION NAME] at this dosage. Page 206 indicated she received [MEDICATION NAME] 10/500 for two (2) doses on 01/19/11 and five (5) doses on 01/20/11, then it was discontinued. Page 211 of the book indicated she had been started on [MEDICATION NAME] 12 mcg patches. These had been applied on 01/21/11 and 01/24/11. Page 212 indicated the resident had been started on [MEDICATION NAME] 5/325. She received four (4) doses on 01/21/11, four (4) doses on 01/22/11, two (2) doses on 01/23/11, and two (2) on 01/24/11. -- 4. The controlled substances book was randomly reviewed with regard to the administration of [MEDICATION NAME]. No issues related to usage were noted. -- 5. The resident was observed in the common area of Mary's Garden on 01/25/11, after lunch. She did not appear to be in pain or exhibit non-verbal indicators of pain. Other residents in the common area were randomly observed and none demonstrated any indicators of pain. General observational tours of the other units did not find any visual or auditory indicators of residents experiencing pain or discomfort. -- 6. The records of Residents #41 and #53, both had sustained falls, were reviewed. No issues related to pain management were found. -- 7. On 01/25/11 at 12:42 p.m., the DON said they had done pain assessments on everyone in the building after the occurrence with Resident #50. -- 8. Based on the staff interviews, observations, review of medical records, and review of other facility documents, it was determined the had identified the deficits in care provided to Resident #50 with respect to assessment of her pain, relevant documentation, administration of [MEDICATION NAME], evaluation of the efficacy of [MEDICATION NAME], notification of the physician, and other related aspects of pain management. Staff had been provided with needed training and those involved had been given one-on-one educational counseling. It was therefore determined the facility had identified the deficient practice and implemented corrective actions to prevent recurrence. No additional deficient practices were identified. Therefore, this citation constitutes past noncompliance with the requirements at ?483.25 - Quality of Care.",2014-03-01
11442,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2010-11-04,353,F,,,UZ0K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of the facility-generated Form CMS-672 (Resident Census and Conditions of Residents) and facility-generated Form CMS-802 (Roster / Sample Matrix), review of the nursing staffing calculation worksheet completed by the facility for the time period of 10/10/10 through 10/23/10, review of payroll records, nursing staff postings, and assignment sheets, review of resident council meeting minutes for 10/18/10, random observations, family interview, and staff interview, the facility failed to provide sufficient direct care nursing staff on the 7:00 a.m. to 3:00 p.m. (7-3) shift to meet the assessed care needs of dependent residents and to also answer call lights in a timely manner. This practice has the potential to affect all residents in this facility. Facility census: 94. Findings include: a) According to the CMS-802 (Roster / Sample Matrix) generated by the facility from data collected through the minimum data set (MDS) assessments, there were ninety-four (94) residents living there at the time of this investigation. b) According to the CMS-672 generated by the facility from data collected through the MDS assessments: For bathing - zero (0) residents were independent, seventy-five (75) residents required the assistance of one (1) or two (2) staff, and nineteen (19) residents were totally dependent. For dressing - four (4) were independent, sixty-eight (68) residents required the assistance of one (1) or two (2) staff, and twenty-two (22) residents were totally dependent. For transferring - five (5) were independent, seventy-four (74) residents required the assistance of one (1) or two (2) staff, and fifteen (15) residents were totally dependent. For toilet use - four (4) were independent, sixty-seven (67) residents required the assistance of one (1) or two (2) staff, and twenty-three (23) residents were totally dependent. For eating - twelve (12) were independent, eighty (80) residents required the assistance of one (1) or two (2) staff, and two (2) residents were totally dependent. For bowel and bladder status, six (6) residents had urinary catheters, fifty-three (53) residents were incontinent of bladder, and thirty-eight (38) residents were incontinent of bowel. For mobility, one (1) resident was bedfast all or most of the time, fifty-five (55) were in a chair most of the time, two (2) were independently ambulatory, and thirty-six (36) ambulated with assistance or an assistive device. For skin integrity, forty-nine (49) received preventive skin care. c) Review of the facility's resident council meeting minutes for 10/18/10 revealed that residents on both wings expressed concerns that their call lights aren ' t answered in a timely manner. They stated this happens on all shifts. Review of the facility ' s resident council meeting minutes of 9/20/10 revealed that there were complaints voiced that staff would turn off call lights before their needs are met, and also that staff needs to respond to call lights instead of just walking by them. d) During random observations on 11/1/10, it was observed that the call light for room [ROOM NUMBER] was lit from 1:30 p.m. An audible alarm monitor began sounding at 1:32 p.m. The resident was observed walking from the bathroom to her bed. When she got into the bed, the alarm stopped sounding. The call light remained on. No staff intervened until 1:42 p.m. It was also observed that the call light in room [ROOM NUMBER] was lit from 3:52 p.m. until staff responded at 4:07 p.m. Two (2) staff members walked by the room, without responding to the call light. During a random observation on 11/2/10, the call light in room [ROOM NUMBER] was lit from 2:41 p.m. until staff intervened at 3:03 p.m. During random observations on 11/3/10, the call light in room [ROOM NUMBER] was lit from 9:08 a.m. until 9:23 a.m. It was then lit again from 9:35 a.m. until 9:48 a.m. At 9:48 a.m., facility LPN, employee #E99 walked to another hall and instructed a nursing assistant to go attend to the call light. The nursing assistant was heard to state, "" I ' ll get it, but we really need two people on this hall. "" On 11/3/10 at 9:52 a.m., when LPN #E99 was asked about the delays in responding to call lights, and whether she felt there was adequate staff, she replied, "" To be honest, no. There are a lot of two-person assists on this wing. "" In another brief conversation at 10:35 a.m., she stated that she feels the staff is really trying to attend to all the residents ' needs, but they just are not able to. e) When interviewed by telephone on 11/2/10 at 10:15 a.m., the complainant, who requested confidentiality stated that there is not enough staff to get the job done, causing unintentional neglect of the residents by the nursing assistants who are not able to attend to their needs in a timely manner. She felt that this was the case on all shifts, although she was most concerned with the day shift. f) The daughter of resident #8 was interviewed on 11/2/10 at 2:30 p.m. She stated that there is not sufficient staff to meet the residents ' needs. She feels this is true on all shifts. She stated that call lights are on "" for a long, long, time. "" She has observed this with her mother ' s light and with other residents as well. She stated that residents are often wet or soiled because there is not enough staff to provide adequate care for them. She related she is concerned that residents may fall trying to get up and do for themselves when staff does not respond for long periods of time. g) Resident #60, who is an [AGE] year old woman that has resided in the facility since 10/22/04, was interviewed on 11/2/10, immediately after the observation that it took over twenty (20) minutes for her call light to be answered, stated that it always takes a long, long time. She said that this instance was better than most. She sometimes has to holler for them or they never come at all. She stated "" It makes them mad, but I can ' t help it. "" Resident #13, who is a [AGE] year old woman that has resided in the facility since 9/18/90, was interviewed on 11/3/10 at 10:00 a.m. She was asked if she felt there was sufficient staff in the facility to meet the residents ' needs. She replied "" No, there is not enough. "" She stated she just came out of the bathroom, and that she had to wait in there for twenty (20) minutes. She stated it has been like that ever since the change of ownership. She stated "" I have seen them walk right by and ignore lights. "" She said she has sat in the bathroom for an hour more than once. She stated that she has complained many times, but it has done no good. h) On 11/1/10 at 3:30 p.m., facility administrator, employee #E147 provided a staffing calculation worksheet for the most recent payroll period of 10/10/10 - 10/23/10. The staffing on 7-3 shift ranged from a low of 13.5 nursing staff on 10/11/10 to a high of 19 on 10/21/10. The average total 7-3 nursing staff for the period was 15.5. i) During an interview on 11/2/10 at 2:09 p.m. facility administrator, employee #E147 reported that staffing was adjusted for census. The general budgeted staffing levels were from 2.89 to 2.92 hours per patient per day (PPD). With a census of 94 the staffing would therefore range from 271.66 to 274.48 hours. The total nursing hours on the staffing calculation worksheet ranged from a low of 246.25 on 10/14/10 to a high of 323.5 on 10/21/10. The average total nursing staff hours for the period was 270.0. During an interview on 1/3/10 at 11:20 a.m., facility director of nursing (DON) stated that although the staffing may be adjusted for census or also at times for acuity, the usual staffing is four (4) nursing assistants and three (3) licensed nurses for each wing, for a total of eight (8) nursing assistants and six (6) licensed nurses. j) During an interview on 11/4/10 at 9:05 a.m., the facility director of nursing (DON) provided call light audit information for 10/10. She stated that the audits were to be compiled for quality assurance study in November, but that the information was not yet summarized for that purpose. Each form was found to contain fields for entry of date, room, time light went on, time light was answered, and signature. A review of the audit sheets found they covered the period of 10/12/10 to 10/31/10 as follows: 10/12/10 5 audits done, 10/13/10 2 audits done, 10/14/10 no audits done, 10/15/10 5 audits done, 10/16/10 4 audits done, 10/17/10 no audits done, 10/18/10 3 audits done, 10/19/10 1 audit done, 10/20/10 13 audits done, 10/21/10 9 audits done, 10/22/10 2 audits done, 10/23/10 11 audits done, 10/24/10 5 audits done, 10/25/10 11 audits done, 10/26/10 8 audits done, 10/27/10 9 audits done, 10/28/10 7 audits done, 10/29/10 8 audits done, 10/30/10 8 audits done, 10/31/10 7 audits done. This represents six (6) call lights timed each day. An interview was conducted with "" A "" wing facility registered nurse (RN), employee #E116, on 11/4/10 at 9:15 a.m. She was asked to briefly explain her role in the call light audits. She indicated that the nurses write down the time they observe a call light come on, and the time it is answered. She stated that if it goes too long, she answers it herself, because she doesn ' t want the resident to wait too long. An interview was conducted with "" B "" wing facility registered nurse (RN), employee #E47, on 11/4/10 at 9:22 a.m. She was asked to briefly explain her role in the call light audits. She indicated that the nurses write down the time they observe a call light come on, and the time it is answered. Each nurse is to do two (2) audits per shift. She stated that if the light is unanswered for ten (10) minutes, she answers it herself. k) Review of the nursing staffing on 11/1/10 and on the staffing calculation worksheet (for the time period of 10/10/10 to 10/23/10) revealed that, while the facility met the State-mandated minimum of 2.25 hours of direct nursing care per resident per day, the staffing levels deployed on the 7-3 shift on 11/1/10 were determined to be inadequate to meet the assessed care needs of all 94 of the facility's residents and also allow staff to answer call lights in a timely manner.",2014-03-01
11443,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,156,D,,,1I0H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to inform rights of their rights by: (a) failing to post the names and current contact information for all pertinent State client advocacy groups, (b) failing to provide accurate appeals information for one (1) of thirty-nine (39) Stage II sample residents, and (c) failing to provide a liability notice to one (1) of thirty-nine (39) Stage II sample residents when Medicare-covered skilled services were discontinued. Resident identifiers: #139 and #2. Facility census: 129. Findings include: a) On 05/11/11 at 11:00 a.m., the surveyor went with the administrator (Employee #200) and the social worker (Employee #129) to find where the required agency postings were located in the facility. It was observed that addresses were not posted at the time. A poster with agency addresses had been in the administrator's office in a framed poster. She said they were taken down so she could change the address of the state agency. The current state agency address will be a year old in July 2011. On 12:46 p.m. on 05/11/11, the administrator presented the surveyors with additional pamphlets, signs, forms, etc. with the advocacy groups names, address and phone numbers listed on it. These were not available at the time of survey. b) Resident #139 Record review revealed that, on 03/17/11, Resident #139 received conflicting notification of transfer / discharge related to which State agency to contact for appeals related to his discharge from the facility to home. Page 2 of the ""Notification of Transfer / Discharge"" listed several State agencies to which a resident may appeal the transfer / discharge decision, although the only correct State agency was the Office of Inspector General's Board of Review. During an interview on the early afternoon of 05/03/11, after request was made for a copy of the information provided to residents upon transfer or discharge, the administrator reported the 2-page ""Notification of Transfer / Discharge"" was not the current form and staff should not be using it. c) Resident #2 A review of this resident's discharge date from Medicare-covered skilled services, during an interview with the business office manager (Employee #147) on 05/10/11 at 4:00 p.m., found the resident was discharged on [DATE], when he used up one hundred (100) days of Medicare Part A services and then returned to Medicaid as the primary payor for his care at the facility. The facility's log of Medicare liability notices was reviewed at this time, and Resident #2's name was not on the log. Employee #147 reported that copies were made of all notices, but there was none available for this resident. Review of the Beneficiary Notices Initiative Summary with Employee #147 found no evidence that Resident #2 was notified that his Medicare Part A days had exhausted. .",2014-03-01
11444,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,159,D,,,1I0H11,". Based on record review and staff interview, the facility failed to obtain written authorization to manage personal funds for two (2) of three (3) residents reviewed. The facility managed funds for these residents but had no written authorization to do so. Additionally, based on observation of the official posting of the availability of resident funds, residents did not have access to petty cash on an ongoing basis. Resident identifiers: #148 and #90. Facility census: 129. Findings include: a) Resident #148 Review of personal funds, on 05/10/11 at 2:30 p.m., with the business office manager (Employee #147) revealed this resident had $91.16 in the resident trust fund account. Review of authorizations to manage resident funds revealed a signed resident trust authorization. It had an ""x"" beside an option indicating the resident did not want the facility to manage her personal funds. -- b) Resident #90 Review of personal funds, with Employee #147 on 05/10/11 at 2:30 p.m., revealed this resident had $9.54 in the resident trust fund account. Review of authorizations to manage resident funds revealed this resident signed a resident trust authorization on 02/01/08. It had an ""x"" beside the option indicating the resident did not want the facility to manage his personal funds. -- c) During the initial tour, on 05/02/11 at 3:00 p.m., a framed notice regarding resident funds was observed outside the business office, stating the times the resident's funds were available at the business office and times the funds were available at the East nursing station. Based on the information on this sign, resident funds were not available from 5:00 a.m. to 8:00 a.m. Monday through Friday, or from 8:00 a.m. to 10:00 a.m. on Saturday and Sunday. During an interview with Employee #147 on 05/10/11 at 2:30 p.m., an inquiry was made regarding when funds were available to the residents. Employee #147 stated the residents had access to their funds twenty-four (24) hours a day, seven (7) days a week. She also stated there was a notice posted to this effect. At that time, Employee #147 was informed the official posting of funds availability did not indicate funds were available twenty-four (24) hours a day, seven (7) days a week. .",2014-03-01
11445,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,225,E,,,1I0H11,". Based on a review of sampled employees' personnel files, a review of the facility's pre-employment screening policies and procedures, and staff interview, the facility failed to complete statewide criminal background checks for five (5) of five (5) sampled employees, in an effort to identify criminal histories that would indicate unfitness for service in a nursing facility. Employee identifiers: #1, #27, #28, #82, and #182. Facility census: 129. Findings include: a) Employees #1, #27, #28, #82, and #182 Review of personnel records for five (5) new employees (#1, #27, #28, #82, and #182) disclosed no evidence that statewide background checks had been completed in an effort to identify criminal histories that would indicate unfitness for service in a nursing facility for each of these employees who were hired for the facility since 01/12/11. Review of the personnel records with the business office manager (Employee ##147), on 05/05/11 at 9:00 a.m., found a third party vendor was completing the background checks for the facility, but there was no evidence the third party vendor had verified with the facility that the background checks were completed. In the mid-afternoon of 05/09/11, a corporate consultant (Employee #202) reported the facility's policy for pre-employment screening did not include specific instructions about how to obtain a statewide background check. The ""Initial Screening of Prospective Applicants"" policy stated, ""Provider will conduct criminal background checks on all perspective applicants..."", but it did not specify how the background checks would be conducted or what the procedure would be followed in order to ensure the background checks were completed. Employee #202 explained that the facility completed fingerprinting on perspective employees and submitted them to a vendor that completed background checks, but they did not keep evidence to verify these actions had been completed. The vendor, in turn, returned a computer printout saying whether the background was completed. However, this printout did not include evidence as to how the background checks were completed. .",2014-03-01
11446,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,226,E,,,1I0H11,". Based on a review of sampled employees' personnel files, a review of the facility's pre-employment screening policies and procedures, and staff interview, the facility failed to develop and implement a policy and procedure that ensured statewide criminal background checks were completed on new hires, to identify criminal histories that would indicate unfitness for service in a nursing facility. Employee identifiers: #1, #27, #28, #82, and #182. Facility census: 129. Findings include: a) Employees #1, #27, #28, #82, and #182 Review of personnel records for five (5) new employees (#1, #27, #28, #82, and #182) disclosed no evidence that statewide background checks had been completed in an effort to identify criminal histories that would indicate unfitness for service in a nursing facility for each of these employees who were hired for the facility since 01/12/11. Review of the personnel records with the business office manager (Employee ##147), on 05/05/11 at 9:00 a.m., found a third party vendor was completing the background checks for the facility, but there was no evidence the third party vendor had verified with the facility that the background checks were completed. In the mid-afternoon of 05/09/11, a corporate consultant (Employee #202) reported the facility's policy for pre-employment screening did not include specific instructions about how to obtain a statewide background check. The ""Initial Screening of Prospective Applicants"" policy stated, ""Provider will conduct criminal background checks on all perspective applicants..."", but it did not specify how the background checks would be conducted or what the procedure would be followed in order to ensure the background checks were completed. Employee #202 explained that the facility completed fingerprinting on perspective employees and submitted them to a vendor that completed background checks, but they did not keep evidence to verify these actions had been completed. The vendor, in turn, returned a computer printout saying whether the background was completed. However, this printout did not include evidence as to how the background checks were completed. .",2014-03-01
11447,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,241,D,,,1I0H11,". Based on observation, the facility failed to ensure privacy during a visit for one (1) of thirty-nine (39) Stage II sample residents. A staff member entered the resident's room without first knocking or asking permission to enter the room. At that time, the resident had a visitor. Resident identifier: #173. Facility census: 129. Findings include: a) Resident #173 On 05/03/11 at 3:10 p.m., a member of the survey team was conducting a Stage I interview with this resident. Without first knocking and/or asking permission to enter the room, Employee #136 (a licensed practical nurse - LPN) came into the room with a rolling blood pressure cart. Employee #136 walked over to the resident and told her she was going to take her blood pressure. While she was taking the resident's blood pressure, Employee #136 looked over at the resident's visitor (a surveyor) and asked the visitor (surveyor) if she was ""doing a diary"" for the resident. .",2014-03-01
11448,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,242,D,,,1I0H11,". Based on family interview, observation, staff interview, and review of the resident tray cards, the facility failed to ensure two (2) of thirty-nine (39) Stage II sample residents had the right to make choices about aspects of life in the facility that are significant to the residents. Resident #63's family complained that Resident #63 was wearing clothing that was not hers and the resident's closet contained clothing that did not belong to the resident. Resident #90's food preferences were not honored. Facility census: 129. Findings include: a) Resident #63 During an interview on 05/03/11 at 3:49 p.m., Resident #63's family reported finding the resident wearing clothing that did not belong to her and looked ""terrible"". The family member stated they complained about this to a staff member and were given a form to fill out. The resident was given clothing from other residents, and she wore ""things that are not hers"". The family member reported finding the resident wearing other residents' clothing even after having complained to the facility about the matter. Observation of the resident's closet, with a licensed practical nurse (LPN - Employee #177) on 05/05/11 at 4:15 p.m., found a 2-piece outfit on a hanger with another resident's name in both pieces of the clothing. Also found folded up in the bottom of the closet were two (2) brassieres that had other residents' names on them. Review of the nursing notes found an entry dated 05/07/11 at 3:00 p.m., stating, ""Spoke to ... concerning closet and rummaging of a roommate. Gave consent to apply a safety lock to assist with the rummaging behavior (sic) of other peers."" -- b) Resident #90 Interview with this resident, on 05/03/11 at 5:44 p.m., revealed he had many food preferences which were not honored by the dietary department. The resident stated he was particularly ""upset"" about getting gravy. He said it makes him sick, and he got it ""last night"". The resident stated he could not understand why he always got gravy, because it was noted as a dislike on his tray slip. Review of the resident's dietary progress notes revealed nothing regarding food preferences. During the morning of 05/05/11, the dietary manager (DM - Employee #21) was asked if food preferences were documented somewhere else. At 10:45 a.m. on 05/05/11, the DM provided a list of Resident #90's food preferences which had been completed on 04/20/11. It indicated gravy as a dislike. On 05/05/11 at 1:30 p.m., an interview was conducted with the resident, with the DM present. The resident stated he was still receiving gravy and that he ""got gravy again last night"". The resident stated his sister was visiting at the time his meal was served, and she ""scraped the gravy off into a cup"". A telephone interview with the resident's sister, at 2:40 p.m. on 05/05/11, confirmed she was visiting the resident at noon on 05/04/11 and the resident was served gravy. She stated she ""scraped it off into a cup"". The resident's sister said she looked at the ""slip"" with his diet on it, and it said ""no gravy"". .",2014-03-01
11449,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,252,E,,,1I0H11,". Based on observation and staff interview, the facility failed to provide a homelike environment during resident dining in the North dining room. Staff walked in and out of the dining room, to an office at the back of the dining room, numerous times during the meals. This was not a homelike environment which de-emphasized the institutional character of the setting. This practice had the potential to affect more than an isolated number of residents who had their meals daily in the North dining room. Facility census: 129. Findings include: a) During observation of resident dining in the North dining room during the evening meal on 05/02/11, several facility staff members were observed continuously coming and going through the dining room into a room at end of the dining room. This gave the appearance that resident dining was not nearly as important as whatever staff members were doing in the room at the end of the dining room. The dining room was an avenue to an office, instead of a homelike area for meals. On 05/04/11, meal service in the North dining room was again observed. Between 12:00 p.m. and 12:20 p.m., a period of twenty (20) minutes, staff members went through the dining room into the room at the back eleven (11) times, and from that room through the dining room nine (9) times. Later on 05/04/11, it was learned the doorway at the end of the dining room led to the office shared by the scheduler and staff development. This doorway also led to a conference room. At 1:00 p.m. on 05/10/11, an interview was conducted with the administrator (Employee #200), who confirmed this was not creating a homelike environment which de-emphasized the institutional character of the setting. .",2014-03-01
11450,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,253,E,,,1I0H11,". Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable resident environment. Prompt housekeeping services were not provided to address a strong, persistent, unpleasant odor of urine in the room of Resident #72, one (1) of thirty-nine (39) Stage II sample residents. Routine maintenance services were not provided to ensure the door to the central shower room on the North unit and the wooden handrails in the corridors on the North, East, and Alzheimer's units were free of damage that prevented the surfaces from being able to be effectively cleaned / sanitized. Resident identifier: #72. Facility census: 129. Findings include: a) Resident #72 Observation, on 05/03/11 at 3:09 p.m., revealed the presence of a strong urine odor in the hallway outside Resident #72's room. Numerous staff was observed walking past the room without intervention for the odor as follows: - At 3:10 p.m., an unidentified aide; - At 3:11 p.m., a nurse (Employee #18); - At 3:12 p.m., a nurse aide (Employee #52); - At 3:13 p.m., a nurse (Employee #85); - At 3:14 p.m., an unidentified housekeeping employee; - At 3:15 p.m., Employee #85 and the housekeeping employee; and - At 3:18 p.m., Employee #85. During an interview with the assistant director of nursing (ADON - Employee #112) on 05/03/11 at 3:22 p.m., she acknowledged the presence of the strong urine smell in Resident #72's room and in the hallway outside his door. A restorative aide (Employee #34) emptied Resident #72's urinary drainage bag, but no odor could be detected in the plastic receptacle into which the urine was drained or in the bathroom when the urine was emptied into the commode; she said the odor may have come from the urinary catheter bag having drained ""urine onto the floor and the smell seeped into the flooring (laminate)"" at some previous point in time, and she agreed the floor on the left side of his bed was a little sticky. The restorative aide checked and did not find any evidence of urinary incontinence by either Resident #72 or his roommate at this time. As Resident #72 was wheeled out of the room in his wheelchair by Employee #34 on 05/03/11 at 3:53 p.m., a strong smell of urine was detected by two (2) surveyors as he passed by in his wheelchair. During an interview with a nurse (Employee #18) on 05/03/11 at 3:53 p.m., she said she changed the urinary drainage bag and sprayed the floor and the wheelchair; she also said Resident #72 received a shower this morning by the hospice aide. Soon after, housekeeping staff mopped the floor in his room. Observation of Resident #72's room, on the morning of 05/04/11, found a slight odor of urine was present; housekeeping had mopped the floor earlier this morning. Observation of Resident #72's room, on 05/05/11 at 11:20 a.m., found there was no odor of urine detected. During an interview with Employee #85 at this time, she said she believed the urine odor came from his socks, where he had stepped onto the floor which had the urine odor. On 05/05/11 at 2:00 p.m., the administrator was informed about the strong urine odor related to Resident #72 and his room, with no further information obtained. -- b) Observations of the safety of handrails and other environmental issues were conducted in the mid afternoon of 05/10/11 with the following concerns identified: - On the East wing corridor from rooms 104 to 106 and room 106 to 108, the wooden handrailing had some rough spots that needed repair. Wooden handrailing in the corridor between rooms 109 and 110 was found to be in the same condition. - On the North wind corridor, handrails near rooms 335 and 337 were rough with areas that could catch clothing, etc. on them, and the handrail outside room 345 had a rough area noted with splinters. - Observations of Alzheimer's unit found the handrailing in the corridor outside of room 202 to be badly splintered. These issues were discussed with the maintenance supervisor (Employee #144) on the afternoon of 05/10/11. He reported there was a plan in place through which the handrails were being replaced and/or sanded and repaired. These issues were also discussed with the administrator on the afternoon of 05/11/11. An undated document was later given to the surveyors, which stated that repairs to handrails would start in the main dining room and progress towards East hall. This was to start in March and be completed by June. There was no provision address needed repairs to rough and damaged handrails that presented safety hazards to residents in other areas of the building. -- c) Observation, at 9:15 a.m. on 05/11/11, found the main door of the central bath on the North unit to be badly scratched and banged up, making the surface not easily cleanable as well as unsightly. This issue was mentioned to the administrator during the afternoon of 05/11/11. .",2014-03-01
11451,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,279,D,,,1I0H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident interview, and staff interview, the facility failed to develop a care plan for one (1) of thirty-nine (39) Stage II sampled residents who had distinct food preferences. Resident identifier: #90. Facility census: 129. Findings include; a) Resident #90 Record review revealed this resident was admitted to the facility on [DATE]. Interview with this resident, on 05/03/11 at 5:44 p.m., revealed he had many food preferences which were not honored by the dietary department. The resident further stated it was "" not necessarily that I don ' t like them, they don ' t like me "" . During the survey, it was confirmed the resident was receiving foods which were noted as dislikes on his tray card. Review of the resident's comprehensive care plan, on the morning of 05/05/11, revealed nothing regarding food preferences and/or foods that did not "" like him "" . This was brought to the attention of the dietary manager (DM - Employee #21) at 10:45 a.m. on 05/05/11. At that time, the DM confirmed there was no care plan for the resident's food preferences. On 05/06/11, the DM provided a care plan, dated 05/06/11, related to preferences for Resident #90. It stated as the problem, ""Resident will report he receives food not on his preferences even if they were not served that day."" There were no associated goals and interventions to assure the resident's known preferences were honored and/or to assure the resident's food preferences were periodically updated. Additionally, the problem, as stated, was not the problem expressed by the resident. The resident was getting foods he previously told the facility he did not like and that did not "" like him "" . His newly written care plan did not address this problem at all. On 05/10/11 at 4:55 p.m., an interview regarding this care plan was conducted with the director of nursing (DON - Employee #49). The DON agreed a care plan for the resident to report to staff was not a sufficient means of addressing this resident's needs. On 05/12/2011 an additional care plan problem was instituted for this resident which stated "" resident states certain foods such as gravy give him diarrhea. Has multiple food dislikes "" . This care plan included nursing staff in assuring the resident did not receive foods that were on his dislike list. .",2014-03-01
11452,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,280,D,,,1I0H11,"**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-nine (39) Stage II sampled residents to address her low [MEDICATION NAME] level. Resident identifier: #82. Facility census: 129. Findings include: a) Resident #82 1. Record review revealed Resident #82 was readmitted from the hospital on [DATE], and her active [DIAGNOSES REDACTED]. Review of lab work revealed Resident #82 had serum [MEDICATION NAME] levels (with the normal reference range between 3.6 - 4.8) as follows: - 3.7 on 12/21/10 - 3.2 on 12/24/10 - 3.5 on 12/25/10 - 3.7 on 02/21/11 - 2.5 on 04/26/11 - 2.8 on 05/05/11 Further review of lab work revealed Resident #82 had total protein levels (with the normal reference range between 6.2 - 8.0) as follows: - 12/21/10 - 7.6 - 12/24/10 - 6.5 - 12/25/10 - 7.0 - 04/26/11 - 5.4 - 05/05/11 - 6.1 -- 2. Review of interdisciplinary (IDT) progress notes and nurses' notes in Resident #82's medical record revealed documentation by the consultant dietitian on 12/30/10, noting, ""... Diet is consistent carb (for DM) & NAS (no added salt), (arrow pointing down) K+ (potassium), (arrow pointing up) Protein (renal). ..."" Subsequent entries, made by the dietary manager on 01/06/11, 01/21/11, 02/21/11, and 03/21/11, also noted the provision of 1-1/2 protein with the resident's diet. On 04/29/11, the dietitian noted, ""... Labs reviewed - 4/26 Alb ([MEDICATION NAME]) 2.5 - moderately depleted visceral protein stores - likely r/t (related to) [MEDICAL CONDITION] / diuretic tx (treatment) ..."" -- 3. Review of the March 2011 recapitulation of physician orders [REDACTED]."" (The word ""protein"" was handwritten, while the rest of the order was typed.) Review of the May 2011 recapitulation of physician's orders [REDACTED]. -- 4. Interview with the dietary manager (Employee #21), on 05/05/11 at 9:56 a.m., revealed that ""1-1/2 protein"" meant the resident was to receive 1-1/2 sized portions of each protein served at each meal. However, the dietary manager stated Resident #82's order for extra protein was not carried over; therefore, this resident had not been receiving the extra protein diet as prescribed by the physician. When asked, Employee #21 stated the resident's diet was for regular consistency, consistent carbohydrate, no added salt, low potassium, with fluid restrictions of 2200 cc per day. She said there was nothing special about the protein for her diet, and Resident #82 ""gets what everybody else gets"" in the way of protein. -- 5. During an interview on 05/05/11 at 10:20 a.m., the dietician agreed that the ""1-1/2 protein"" ordered for Resident #82 meant that, with each protein item served at each meal, the resident was to receive a 1-1/2 portioned size. According to the dietician, the first carry-over of physician's orders [REDACTED]. The dietician said that, upon admission in December 2010, Resident #82 was on a regular diet, and she calculated Resident #82's daily protein needs of 44 - 55 grams per day based on her ideal body weight range of 86 - 106 pounds, and not on her admission weight of 194 pounds. The dietician said Resident #82 received about 90 grams of protein per day with the diet now ordered and the ""1-1/2"" portion size would equal 135 grams of protein per day. -- 6. Resident #82's most current care plan, which was last reviewed by the interdisciplinary team on 03/30/11 (with additional handwritten entries added after that date), included the following problem statements related to nutrition (quoted as written): - ""111 - therapeutic diet - wt (weight) fluctuates due to [MEDICAL CONDITION] - wt loss desired"" (dated 01/12/11) - ""Non-compliant /c (with) diet & fluid rest (restriction)"" (dated 04/28/11) - ""181 - Risk for skin breakdown related to diabetes, [MEDICAL CONDITION], and [MEDICAL CONDITION]"" (dated 01/06/11) - ""[MEDICAL CONDITION]"" (dated 03/30/11) None of the above problems, nor any of the other problems on the comprehensive care plan, included an intervention to provide the resident with addition protein. .",2014-03-01
11453,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,323,E,,,1I0H11,". Based on observation, review of material safety data information, and staff interview, the facility failed to assure the resident environment remained as free of accident hazards as possible. A hazardous cleaning product was left in a resident room, hazardous cleaning products were stored in an unlocked cabinet in the North shower room, and wooden handrailing in the corridors had splintered and/or rough areas, creating a potential for resident injury. These practices had the potential to affect more than an isolated number of residents. Facility census: 129 Findings include: a) On 05/03/11 at 2:18 p.m., a cleaning product in a spray bottle was observed in room 311. The name of the product was ""T B QUAT"". The bottle contained directives to ""keep out of reach of children"" and noted the product was a ""hazard to humans and domestic animals"". Review of the material safety data sheet for the product revealed the following identified hazards: - ""Corrosive to eyes. Will cause eye burns, Permanent eye damage or blindness may result without immediate first aid treatment. Harmful or fatal if swallowed."" - For ingestion: ""May cause nausea, vomiting, and swelling of the larynx, and skeletal muscle paralysis affecting ability to breath, circulatory shock, and convulsions."" - ""Inhalation of mists may cause irritation to the nose, throat, and mucous membranes. Tissue damage and Pulmonary irritation. Severity depends upon degree of exposure."" - For skin contact: ""Contact may cause mild to severe irritation, drying, and dermatitis. Health effects depend on degree of exposure."" At 2:35 p.m. on 05/03/11, the director of nursing (DON - Employee #49) was asked to point out where the product should be stored. The DON went to the North shower room and pointed out the cabinet in which the products were stored. The cabinet had an unlocked lock on the doors. Upon inquiry, the DON confirmed the cabinet was supposed to be locked. -- b) Observations of the safety of handrails and other environmental issues were conducted in the mid afternoon of 05/10/11 with the following concerns identified: - On the East wing corridor from rooms 104 to 106 and room 106 to 108, the wooden handrailing had some rough spots that needed repair. Wooden handrailing in the corridor between rooms 109 and 110 was found to be in the same condition. - On the North wind corridor, handrails near rooms 335 and 337 were rough with areas that could catch clothing, etc. on them, and the handrail outside room 345 had a rough area noted with splinters. - Observations of Alzheimer's unit found the handrailing in the corridor outside of room 202 to be badly splintered. These issues were discussed with the maintenance supervisor (Employee #144) on the afternoon of 05/10/11. He reported there was a plan in place through which the handrails were being replaced and/or sanded and repaired. These issues were also discussed with the administrator on the afternoon of 05/11/11. An undated document was later given to the surveyors, which stated that repairs to handrails would start in the main dining room and progress towards East hall. This was to start in March and be completed by June. There was no provision address repairs to rough and damaged handrails that presented safety hazards to residents in other areas of the building. .",2014-03-01
11454,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,325,D,,,1I0H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide a physician-ordered therapeutic to one (1) of thirty-nine (39) Stage II sample residents in an effort to maintain acceptable parameters of nutritional status such as protein levels. Resident identifier: #82. Facility census: 129. Findings include: a) Resident #82 1. Record review revealed Resident #82 was readmitted from the hospital on [DATE], and her active [DIAGNOSES REDACTED]. Review of lab work revealed Resident #82 had serum [MEDICATION NAME] levels (with the normal reference range between 3.6 - 4.8) as follows: - 3.7 on 12/21/10 - 3.2 on 12/24/10 - 3.5 on 12/25/10 - 3.7 on 02/21/11 - 2.5 on 04/26/11 - 2.8 on 05/05/11 Further review of lab work revealed Resident #82 had total protein levels (with the normal reference range between 6.2 - 8.0) as follows: - 12/21/10 - 7.6 - 12/24/10 - 6.5 - 12/25/10 - 7.0 - 04/26/11 - 5.4 - 05/05/11 - 6.1 -- 2. Her most current care plan, which was last reviewed by the interdisciplinary team on 03/30/11 (with additional handwritten entries added after that date), included the following problem statements related to nutrition (quoted as written): - ""111 - therapeutic diet - wt (weight) fluctuates due to [MEDICAL CONDITION] - wt loss desired"" (dated 01/12/11) - ""Non-compliant /c (with) diet & fluid rest (restriction)"" (dated 04/28/11) - ""181 - Risk for skin breakdown related to diabetes, [MEDICAL CONDITION], and [MEDICAL CONDITION]"" (dated 01/06/11) - ""[MEDICAL CONDITION]"" (dated 03/30/11) None of the above problems, nor any of the other problems on the comprehensive care plan, included an intervention to provide the resident with addition protein. -- 3. Review of interdisciplinary (IDT) progress notes and nurses' notes in Resident #82's medical record revealed documentation by the consultant dietitian on 12/30/10, noting, ""... Diet is consistent carb (for DM) & NAS (no added salt), (arrow pointing down) K+ (potassium), (arrow pointing up) Protein (renal). ..."" Subsequent entries, made by the dietary manager on 01/06/11, 01/21/11, 02/21/11, and 03/21/11, also noted the provision of 1-1/2 protein with the resident's diet. On 04/29/11, the dietitian noted, ""... Labs reviewed - 4/26 Alb ([MEDICATION NAME]) 2.5 - moderately depleted visceral protein stores - likely r/t (related to) [MEDICAL CONDITION] / diuretic tx (treatment) ..."" -- 4. Review of the March 2011 recapitulation of physician orders [REDACTED]."" (The word ""protein"" was handwritten, while the rest of the order was typed.) Review of the May 2011 recapitulation of physician's orders [REDACTED]. -- 5. Interview with the dietary manager (Employee #21), on 05/05/11 at 9:56 a.m., revealed that ""1-1/2 protein"" meant the resident was to receive 1-1/2 sized portions of each protein served at each meal. However, the dietary manager stated Resident #82's order for extra protein was not carried over; therefore, this resident had not been receiving the extra protein diet as prescribed by the physician. When asked, Employee #21 stated the resident's diet was for regular consistency, consistent carbohydrate, no added salt, low potassium, with fluid restrictions of 2200 cc per day. She said there was nothing special about the protein for her diet, and Resident #82 ""gets what everybody else gets"" in the way of protein. -- 6. During an interview on 05/05/11 at 10:20 a.m., the dietician agreed that the ""1-1/2 protein"" ordered for Resident #82 meant that, with each protein item served at each meal, the resident was to receive a 1-1/2 portioned size. According to the dietician, the first carry-over of physician's orders [REDACTED]. The dietician said that, upon admission in December 2010, Resident #82 was on a regular diet, and she calculated Resident #82's daily protein needs of 44 - 55 grams per day based on her ideal body weight range of 86 - 106 pounds, and not on her admission weight of 194 pounds. The dietician said Resident #82 received about 90 grams of protein per day with the diet now ordered and the ""1-1/2"" portion size would equal 135 grams of protein per day. -- 7. During an interview with the administrator on 05/05/11 at approximately 1:30 p.m., these findings were discussed, and she agreed there was no pre-[MEDICATION NAME] in Resident #82's medical record. -- 8. Further record review revealed a physician's telephone order, dated 05/09/11 at 7:45 p.m., to discontinue the 1-1/2 protein portions. .",2014-03-01
11455,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,356,C,,,1I0H11,". Based on observation and staff interview, the facility failed to post nursing staffing information which contained all the elements required by this regulation. In addition, the posted information was not documented in a clear, readable format. This practice had the potential to affect all facility residents, families, and guests. Facility census: 129. Findings include: a) During tour on 05/02/11 at 3:00 p.m., observation of the posted nursing staffing information found it did not differentiate between registered nurses and licensed practical nurses. Additionally, it was not documented in a clear manner that any person reviewing it could understand. The confusion associated with reading the form was confirmed by the staff scheduler (Employee #162) during an interview at 3:45 p.m. on 05/02/11. .",2014-03-01
11456,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,366,E,,,1I0H11,". Based on observation and staff interview, the facility failed to ensure staff offered food substitutes to five (5) randomly observed residents when they did not eat their entrees at the evening meal on 05/02/11. Resident identifiers: #55, #114, #13, #65, and #147. Facility census: 129. Findings include: a) Residents #55, #114, #13, #65, and #147 During the evening meal service beginning at 5:30 p.m. on 05/02/11, observation found these five (5) residents left the North dining room between 5:30 p.m. and 5:50 p.m.; none of the five (5) had eaten their entrees. Staff members were in the dining room assisting residents who required spoon feeding and other assistance; however, no one acknowledged these residents leaving, and no one offered any of them a substitute for their uneaten entrees. On 05/10/11 at 1:00 p.m., this was discussed with the administrator (ADM - Employee #200). At that time, the ADM confirmed staff should monitor residents who feed themselves, as well as those who required assistance, to assure all residents are offered substitutions as needed. .",2014-03-01
11457,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,371,F,,,1I0H11,". Part I -- Based on observation, record review, 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: 129. Findings include: a) Observations of the dietary department, with the dietary manager (Employee #21) as part of the initial tour on 05/02/11 at 3:00 p.m., found large stainless steel mixing bowls were still wet when being stored and the shelf on which they were stored was wet. Review of the recent county sanitarian report, dated 02/23/11, found the dietary department was cited for not allowing pans to air dry before stacking them. b) Also found during the initial tour were the following: - Plastic containers of whole and skim milk in the walk-in refrigerator were not dated when opened, so dietary staff could determine how long each product had been opened and whether it was still safe for consumption. - Oven doors, when opened, were found to have food debris spilled across the edges and to be in need of cleaning. c) Observation of nourishment station on the North unit, on 05/10/11 at 2:40 p.m., found in the refrigerator a open / half-empty container of honey-thickened liquid that was not dated when opened. This finding was related to the dietary manager at 1:00 p.m. on 05/11/11. -- Part II -- Based on observation, review of the facility's hand washing policy, and staff interview, the facility failed to ensure two (2) of three (3) employees (#58 and #39) practiced effective hand hygiene during meal service to prevent the potential spread of infection. This had the potential to affect more than an isolated number of residents. Facility census: 129. Findings include: a) Employee #39 During the evening meal service on 05/02/11, observation found a nursing assistant (Employee #39) distributing a meal tray to Resident #107 in the resident's room; while doing so, Employee #39 touched the resident's overbed table and water pitcher. Without washing hands or using hand sanitizer, Employee #39 then went to the food cart and obtained another tray, which he served to Resident #36. The employee then washed his hands before returning to the food cart to obtain another resident's meal tray for distribution. This finding was reported to the administrator at approximately 1:30 p.m. on 05/05/11. b) Employee #58 During the evening meal service on the dementia unit on 05/02/11 at 5:30 p.m., observation found a registered nurse (RN - Employee #58) washed her hands and then turned off the water faucet before obtaining a paper towel. Review of the facility's policy and procedure for hand washing (dated 01/2010) found in Section C at Item 3: ""When washing hands with soap and water, wet hands first with water, apply soap and rub hands together vigorously for at least 20 seconds (Centers for Disease Control (CDC), 2010) covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet."" The above was reviewed with the administrator at 3:30 p.m. on 05/10/11. .",2014-03-01
11458,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,425,D,,,1I0H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, a resident received a daily dose of Lisinopril (an ACE inhibitor used to treat hypertension) for five (5) consecutive days even though his record noted he was allergic to this classification of drugs, and he received one (1) of these doses after the physician discontinued the medication due to the allergy. Resident identifier: #61. Facility census: 129. Findings include: a) Resident #61 Observation during medication pass revealed Resident #61 received a dose of Lisinopril 2.5 mg at approximately 9:00 a.m. on 05/10/11. Record review revealed a physician's telephone order, dated 05/09/11 at 9:00 a.m., with clarification of orders to ""D/C (discontinue) Lisinopril - allergic to Ace Inhibitors."" Review of the medication administration record (MAR) for May 2011 revealed Resident #61 received Lisinopril 2.5 mg orally daily at 9:00 a.m. on 05/06/11, 05/07/11, 05/08/11, 05/09/11, and 05/10/11. In the ""allergies [REDACTED]. Review of the monthly recapitulation of physician's orders [REDACTED]. Also found on the monthly recap was an order for [REDACTED]. These orders were checked by a nurse (Employee #167) as attested by her signature which was dated for 05/05/11. Further review of the physician's telephone orders found an order dated 04/14/11 at 6:00 p.m., stating ""allergies [REDACTED]. During an interview with a nurse (Employee #18) on 05/10/11 at approximately 4:30 p.m., she agreed the order to stop the Lisinopril was written on 05/09/11 at 9:00 a.m., but the MAR was initialed to indicate this medication was administered by the nurse at 9:00 a.m. on 05/10/11. Employee #18 agreed the clarification order dated 05/09/11 noted the resident was allergic to ACE Inhibitors, as did both the MAR and the monthly recapitulation of physician's orders [REDACTED]. Subsequent record review found an incident report was completed on 05/10/11 at 5:00 p.m., and the physician was notified that the Lisinopril (which was discontinued on 05/09/11) was erroneously given at 9:00 a.m. 05/10/11. Actions taken included monitoring Resident #61's blood pressure and removing the Lisinopril from the medication cart; nursing staff also informed the resident of the occurrence. Record review, on 05/11/11, revealed a physician's progress note dated 05/11/11, stating Resident #61 was recently readmitted from the hospital where he was treated with Lisinopril in the hospital and at the facility without problem, and noting that his history include an ACE inhibitor allergy. The physician clarified that Resident #61 did not have an allergy to Lisinopril or to ACE inhibitors. The physician cancelled the ACE inhibitor allergy notation on his record but left the resident off of the Lisinopril. During an interview with the DON in the early morning 05/11/11, she clarified that Resident #61 actually did not have an allergy to ACE inhibitors but, by history, was noted he was not to be on ACE inhibitors because of his [DIAGNOSES REDACTED]. .",2014-03-01
11459,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,441,E,,,1I0H11,". Based on observation, review of the facility's hand washing policy, and staff interview, the facility failed to ensure two (2) of three (3) employees (#58 and #39) practiced effective hand hygiene during meal service to prevent the potential spread of infection. This had the potential to affect more than an isolated number of residents. Facility census: 129. Findings include: a) Employee #58 During the evening meal service on the dementia unit on 05/02/11 at 5:30 p.m., observation found a registered nurse (RN - Employee #58) washed her hands and then turned off the water faucet before obtaining a paper towel. Review of the facility's policy and procedure for hand washing (dated 01/2010) found in Section C at Item 3: ""When washing hands with soap and water, wet hands first with water, apply soap and rub hands together vigorously for at least 20 seconds (Centers for Disease Control (CDC), 2010) covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet."" The above was reviewed with the administrator at 3:30 p.m. on 05/10/11. b) Employee #39 During the evening meal service on 05/02/11, observation found a nursing assistant (Employee #39) distributing a meal tray to Resident #107 in the resident's room; while doing so, Employee #39 touched the resident's overbed table and water pitcher. Without washing hands or using hand sanitizer, Employee #39 then went to the food cart and obtained another tray, which he served to Resident #36. The employee then washed his hands before returning to the food cart to obtain another resident's meal tray for distribution. This finding was reported to the administrator at approximately 1:30 p.m. on 05/05/11. .",2014-03-01
11460,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2010-11-18,225,E,,,FROJ11,". Based on review of facility documents, family interview, and staff interview, the facility failed to ensure allegations of abuse, neglect, and misappropriation of resident property were reported and investigated in accordance with State law for three (3) of three (3) allegations reviewed. Resident identifiers: #26, #105, and #44. Facility census: 104. Findings include: a) Resident #26 Review of facility documents found that, on 09/23/10, Resident #44 complained to the social worker (Employee #88) that she had given a check received from her daughter for $150.00 to a staff member to deposit into her resident trust account. The resident further stated the check was never credited to her account. On 09/24/10, Employee #88 reached the following conclusion: ""Resident was unable to give specifics of check nor exact time and place when check was allegedly given to (staff). No evidence in place to support existence of check."" Further review found this resident's allegation of misappropriation of property had been handled as an in-house complaint and was not reported to State officials, including the State survey and certification agency, as required. Employee #88 was asked if he had called to daughter to determine whether she had provided the resident with a check for $150.00 prior to reaching this conclusion. He stated, on the afternoon of 11/17/10, he had not contacted the resident's daughter. After this prompting, Employee #88 contacted the resident's daughter and determined the daughter had sent the resident a check for $150.00 on 07/05/10, and the check had been deposited to the resident's account on 09/14/10. The facility failed to assure this allegation of misappropriation of resident property was immediately reported and thoroughly investigated as required. -- b) Resident #105 During an interview on 10/27/10 at 3:45 p.m., a family member stated that, while his mother was a resident at the facility, he had visited and found her soaked with urine. He stated he reported this to the administrator. An interview with the administrator, on 11/17/10 at 4:00 p.m., confirmed Resident #105's family member had complained to her of finding his mother wet. The administrator could provide no evidence that this allegation of neglect had been reported and a thorough investigation conducted. -- c) Resident #44 Review of facility documents found Resident #44 reported that, on 09/02/10, she had asked a nursing assistant to put her in bed, and the nursing assistant pushed her down in the bed by her shoulder. Further review found no evidence that any investigation into the validity of this resident's allegation had been conducted by the facility. The facility could provide no evidence that a statement had been obtained from the alleged perpetrator, the resident, or other staff members working at the time the alleged incident occurred. Additionally, it was determined that the required five-day follow-up report had not been faxed until 09/11/10. .",2014-03-01
11461,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2010-11-18,240,G,,,FROJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, medical record review, ambulance personnel interviews, and staff interview, the facility failed to promote care for one (1) of nine (9) sampled residents in an environment that enhanced each resident's quality of life. A facility staff member forced Resident #49 to attend an appointment with a psychiatrist against her will, despite the resident's repeated and vocal statements that she did not want to go. The resident was placed on a gurney, loaded into an ambulance, and subjected to a two-hour trip to attend an appointment which she expressly did not want to attend. It was determined the resident arrived at the appointment in extreme emotional and physical distress. Resident identifier: #49. Facility census: 104. Findings include: a) Resident #49 An interview with Resident #49's daughter, on 11/15/10 at 7:42 p.m., found the daughter was present at a psychiatrist's office on 11/02/10 when her mother arrived by ambulance for a scheduled appointment. The daughter stated her mother was very upset, crying, and extremely short of breath. She relayed that her mother reported to her ""they had thrown her out and made her go"". She stated her mother was so upset that she was unable to interact with the psychiatrist and that she (the daughter) had to answer the questions posed to her mother by the psychiatrist due to her mother's emotional distress. She stated that both ambulance personnel told her that her mother had refused to go, but the nurse made them take her. An interview was conducted with the resident's son and medical power of attorney representative (MPOA) at 8:10 p.m. on 11/15/10. He stated that he visited the facility on 11/01/10, and was informed that his mother had an appointment with the psychiatrist the following day. He stated he informed Employee #98 (a licensed practical nurse - LPN), ""If there was any way possible, I would like her to go, but she probably won't."" He stated his mother had regularly refused to attend appointments outside the facility and he had always been notified by nursing staff she was refusing to go. He stated that neither he nor any staff at the facility had forced his mother to attend an appointment against her wished until this incident. He stated that, if the nurse had contacted him, he would have had them cancel the appointment. He stated his mother still refers to the incident and continues to be upset. Review of Resident #49's medical record found [DIAGNOSES REDACTED]. The resident was receiving seven (7) medications for treatment of [REDACTED]. Review of the resident's most recent minimum data set (MDS) assessment, with an assessment reference date (ARD) of 10/14/10, found the resident was assessed as having no hearing difficulty, demonstrating clear speech and understanding of others, and displaying the ability to make herself understood. Her cognitive skills were assessed as modified independence - with some difficulty in new situations only. Review of the nursing notes found the resident was afforded the right to refuse physician appointments on 05/03/10, 05/12/10, 06/04/10, 07/20/10, 07/29/10, 08/19/10, and 09/28/10. An interview with a member of the ambulance crew (AC) who took the resident to the 11/02/10 appointment (AC #1) was conducted at 12:20 p.m. on 11/17/10. He relayed that Resident #49 was alert and oriented and able to answer questions appropriately. He stated the resident repeatedly verbalized that she did not want to go. He stated she was very upset when they arrived at the appointment and accused them of throwing her on a cot and kidnapping her. He stated that neither he nor the second AC personnel wanted to take the resident after she had refused, but the nurse insisted that they take her. He stated the nurse told them that the POA wanted her to go so they had to take her. An interview with AC #2 was conducted via telephone at 3:30 p.m. on 11/18/10. He stated that, when he arrived with AC #1, the resident was using the porta potty. He stated the resident said four (4) or five (5) times that she did not want to go. He stated the resident was alert and oriented and answered questions appropriately. He stated the nurse insisted that the resident had to go, that her son was POA and wanted her to go, and that they had to take her. He stated that, when they arrived at the appointment, the resident could hardly breath and told her daughter that she had been kicked out of the nursing home. An interview with Employee #98 was conducted at 2:40 p.m. on 11/18/10. She confirmed she was the nurse who sent the resident out for the appointment on 11/02/10. She confirmed that Resident #49 had refused to go when the ambulance crew came to pick her up. She agreed she told the ambulance crew that the family wanted her to go and they had to take her. She stated that the resident had been yelling out constantly for help and calling the family in the middle of the night. She stated the son was in wanting a ""psych"" evaluation to get medicine to make her sleep. When inquiry was made concerning a resident's right to refuse treatment, Employee #98 stated that, if they do not have capacity and the family wants them to go to an appointment, ""then I make them go unless the family calls and tells me that the resident does not have to go."" She stated that, since the family did not call, she forced the resident to go. When asked if she made any attempts to call the family to inform them that the resident had refused to go to the appointment, she stated that she did not try to call them. An interview was conducted with the administrator and director of nursing at 4:45 p.m. on 11/18/10. Both stated that a resident cannot be forced to go to an appointment if they refuse. The DON stated the family should be notified and the appointment rescheduled. .",2014-03-01
11462,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2010-11-18,246,E,,,FROJ11,". Based on resident interview and review of facility records,the facility failed to assure nine (9) of nine (9) sampled residents received prompt assistance when their call bells were activated. Resident identifiers: #95, #78. #58, #67, #6, #25, #49, #44, and #105. Facility census: 104. Findings include: a) Resident #95 In an interview conducted on 11/17/10 at 9:15 a.m., Resident #98 stated that she has great difficulty, at times, getting staff to answer her call light. She stated she has had to wait on occasion from thirty (30) minutes to one (1) hour for assistance. Following the resident interview, a licensed practical nurse (LPN - Employee #99) was noted to be outside the resident's room with a medication cart. When asked how she supervised the unlicensed staff to assure that resident call lights were answered in a timely manner, Employee #99 stated that staff members carry beepers to let them know when a resident's light has gone off. When asked to inspect her beeper, the nurse stated that she had let the nursing assistant (NA) use it. On 11/18/10 at 2:05 p.m., the administrator provided a document which identified how the beeper system operates. Review of the document found that, when a resident activates a call light, the beeper of the NA assigned to the resident goes off. If the call light is not answered after 2.8 minutes, the beepers of NAs on the second wing sound. If the call light is not answered after 8.4 minutes, the nurse's beeper sounds. If the call light is not answered after 11.2 minutes, the beeper of the clinical care supervisor (CCS) sounds. If the call light is not answered within 14 minutes, the beeper of the director of nursing (DON) sounds. The administrator was asked to provide documentation of the wait times for assistance after the call light was activated by Resident #95 for 10/19/10, 10/30/10, and 11/06/10. Review of the information provided found Resident #95's call light was not answered in a timely manner, with the following intervals found between the time the resident activated her call light and the time it was answered by staff: 10/19/10 at 10:54 a.m. - 20.6 minutes 10/30/10 at 6:24 p.m. - 33.9 minutes 10/30/10 at 7:13 p.m. - 26.0 minutes 11/06/10 at 9:27 a.m. - 25.6 minutes 11/06/10 at 12:12 p.m. - 54.4 minutes 11/06/10 at 1:25 p.m. - 80.6 minutes 11/06/10 at 7:09 p.m. - 25.0 minutes -- b) Resident #78 Review of the wait times for assistance after activating the call bell found the resident's call bell was activated for 123.2 minutes on 11/06/10 at 8:06 p.m., before staff responded. -- c) Resident #58 Review of the call bell activation document provided by the administrator found the resident experienced the following wait times: 11/06/10 at 10:23 a.m. - 111.6 minutes 11/06/10 at 7:07 a.m. - 82.1 minutes 11/06/10 at 9:33 p.m. - 35.5 minutes 11/06/10 at 8:38 p.m. - 31.0 minutes 11/06/10 at 5:14 a.m. - 35.4 minutes -- d) Resident #67 Review of the call bell activation document provided by the administrator found the resident experienced the following wait times: 11/06/10 at 11:37 a.m. - 57.5 minutes 10/30/10 at 10:26 p.m. - 23.4 minutes -- e) Resident #6 Review of the call bell activation document provided by the administrator found the resident experienced the following wait times: 11/06/10 at 9:10 p.m. - 38.1 minutes 10/30/10 at 8:44 a.m. - 33.6 minutes -- f) Resident #25 Review of the call bell activation document provided by the administrator found the resident experienced the following wait times: 10/30/10 at 12:03 p.m. - 39.4 minutes 10/30/10 at 12:57 p.m. - 35.6 minutes 11/06/10 at 1:27 p.m. - 21.5 minutes -- g) Resident #49 Review of the call bell activation document provided by the administrator found the resident experienced the following wait times: 11/06/10 at 3:30 a.m. - 27.2 minutes 11/06/10 at 7:26 a.m. - 23.0 minutes 10/30/10 at 5:52 p.m. - 20.5 minutes -- h) Resident #105 Review of the call bell activation document provided by the administrator found the resident waited 41.0 minutes on 10/11/10 at 2:16 p.m. after the call bell was activated. -- i) Resident #44 Review of the call bell activation document provided by the administrator found the resident waited 16.5 minutes on 10/19/10 at 6:17 p.m. after the call bell was activated.",2014-03-01
11463,SUMMERSVILLE REGIONAL MEDICAL CENTER D/P,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2010-10-20,224,D,,,H9I611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and family interview, the facility failed to obtain approval from the Social Security Administration before it, while serving as an organizational representative payee, reimbursed Summersville Memorial Hospital for medical debts in arrears for one (1) of twenty-three (23) Stage II residents. Resident identifier: #28. Facility census: 49. Findings include: a) Resident #28 Record review revealed Resident #28 was admitted to Summersville Memorial Hospital's skilled nursing unit on [DATE], and expired at the facility on [DATE]. Review of the resident trust fund accounting information revealed the facility paid a total of $733.01 to Summersville Memorial Hospital from Resident #28's personal fund account maintained by the facility on [DATE], [DATE], and [DATE], for services incurred at Summersville Memorial Hospital on [DATE], [DATE], [DATE], [DATE], and [DATE] - all of which were debts made prior to her admission to the skilled nursing unit. During a telephone interview with the resident's former medical power of attorney representative (MPOA) and spouse on [DATE] at approximately 8:00 p.m., they spoke their belief that the facility should have forwarded any extra money the resident had in her personal account to the resident's burial fund rather than paying bills that were five (5), six (6), and seven (7) years old and which incurred when she resided in the acute care portion of the facility. During an interview with the staff member responsible for patient accounts (Employee #130) on [DATE] at 9:30 a.m., she said the skilled nursing unit is a subdivision of Summersville Memorial Hospital, and their tax identification numbers are the same. She handles accounts for the skilled nursing unit and explained that Resident #28's old debts to Summersville Memorial Hospital had been turned over to a collection agency. She said she assumed that, if a resident had a previous bill from any hospital or other bill (such as an unpaid electric bill), the facility managing the funds would pay outstanding debts presented. She produced evidence the Social Security Administration (SSA) designated Summersville Memorial Hospital to serve as Resident #28's organizational representative payee on [DATE]. On page 3 of the Advance Notification of Representative Payment form from the SSA dated [DATE], the facility answered ""no"" to question #11, when it asked if the claimant (Resident #28) was ""indebted to your institution for past care and maintenance"". Employee #130 stated that, at that time, the skilled nursing unit was unaware of the past due debts owed to Summersville Memorial Hospital; it was not until the bad debts were turned over to a collection agency and the past due bills were presented to the facility for payment on [DATE], [DATE], and [DATE] (totaling $733.01) that the staff at the skilled nursing unit became aware of the debt. When asked if the facility had requested permission from the SSA to pay those outstanding debts to Summersville Memorial Hospital before making the payments, Employee #130 said they had not, and she was not aware that they needed to obtain this permission, since they were the resident's representative payee. .",2014-02-01
11464,SUMMERSVILLE REGIONAL MEDICAL CENTER D/P,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2010-10-20,257,C,,,H9I611,". Based on the results of the complaint investigation (State Complaint Reference # ), it was determined the facility failed to maintain a comfortable building temperature of at least 71 degrees Fahrenheit (F). Facility census: 51. Findings include: a) The National Weather Service (NOAA: www.weather.gov/climate/) temperature archives indicate the outside temperature in the greater Beckley area, beginning on 09/26/10 and continuing through 10/04/10 - a nine (9) day period, was no greater than 69 degrees F. The daily low temperature during this time period was no greater than 58 degrees F. The lowest daily temperature during this time period was 38 degrees F. on 10/02/10. When questioned as to when the facility heating system became functional, the facility's administrator stated an attempt to activate the heating system had failed on 10/01/10 due to a faulty valve. The valve and the heating system became functional on 10/04/10. Without a functional heating system, it would not be possible to maintain the building temperature at a minimum of 71 degrees F during this time period. .",2014-02-01
11465,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-10-19,241,D,,,SHO311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview and staff interview, the facility staff failed to treat residents with respect. Staff walked past Resident #71 who was requesting assistance without acknowledging her presence or her request. When interviewed, Resident #71 (who was alert and oriented) reported staff members frequently did not identify themselves to her when giving her care. The resident said she felt like staff treated her like a child. This was observed to be true for one (1) of four (4) sampled residents. Resident identifier: #71. Facility census: 118. Findings include: a) Resident #71 At the initial unannounced entrance to the facility on [DATE] at 3:30 p.m., Resident #71 was observed standing in the doorway of her room waving a water pitcher in the air and saying in a loud voice, ""I need some water. Will you get me some water?"" As she was making this request, staff members were observed to walk past her and not pay attention to her. A nurse was down the hall passing medications, and two (2) nursing assistants walked past her without saying anything. Resident #71, when interviewed at 4:10 p.m. on 10/17/10, stated she had tried to get the staff to help her several times, but ""some of them just run from you."" When asked if she knew the names of the staff members that she has difficulty getting help from, she stated, ""No, because they do not tell you their name and probably don't want you to know it."" She then named several staff members who did treat her respectfully and stated, ""They were wonderful and very nice, but some of them just run from you and ignore you."" The resident stated, ""I do not appreciate being treated like I am a child."" This surveyor turned on the call light in Resident #71's room at 4:15 p.m. on 10/17/10. The call light was promptly answered at 4:16 p.m. A nursing assistant (Employee #56) came in the room and asked, ""What do you need?"" while walking past this resident and looking at the roommate. Resident #71 told this nursing assistant, ""I have been trying to get you to help me, and you would not even stop and see what I wanted."" The nursing assistant responded, ""You caught me in a run."" The nursing assistant was asked by this surveyor what her name was, because she wore no name tag, and she was identified herself. The resident stated she did not know this employee's name, because ""The staff here never tell you their names, but she is one of the ones who ignored me earlier."" Employee #56 proceeded to assist the resident's roommate (Resident #24) to the bathroom. Another staff member then came in, and Employee #56 told her that she needed to go to the bathroom. Resident #71 then asked, ""Who is assigned to this room?"" Employee #56 told her the name of her assigned caregiver. Resident #71 stated she did not know who that was. She then stated, ""I know their names if they tell me,"" and she again named staff members by name and said, ""They treat you wonderful, but some don't even tell you their name."" Medical record review revealed Resident #71 was alert / oriented and had capacity to understand and make her own informed health care decisions. She lived alone and came to the facility following a knee replacement. She did not have any long-term or short-term memory problems and was independent with cognitive skills for daily decision-making. The social worker (Employee #53) was notified of the above observations at 10:30 a.m. on 10/18/10. At 11:00 a.m., this surveyor accompanied this social worker to interview Resident #71. The resident described to the social worker the incident that had occurred the day before, and the social worker initiated an investigation into the incident at that time. .",2014-02-01
11466,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-10-19,242,D,,,SHO311,". Based on observation, confidential family interview, and staff interview, the facility did not always honor residents' food likes and dislikes. Resident #78 was served beets for dinner, even though this was specifically listed on her tray card as one (1) of the two (2) food items this resident did not like. This was identified during one (1) random meal observation on 10/17/10. Facility census: 118. Findings include: a) Resident #78 During initial tour of the facility on 10/17/10 at 3:40 p.m., interviews were conducted with family members and alert / oriented residents. In one (10 confidential interview, a family member who visited frequently reported the facility staff did not honor residents' food preferences, stating, When you tell them you do not like something, you seem to get it anyway."" This family member did report that staff will obtain substitute food items upon request. During an observation on 10/17/10 at 6:00 p.m., a test tray was requested to replace the last tray served on the hall (to check the temperature of food items at the time of service). This tray was intended for Resident #78. The temperature of food items on the tray were within an acceptable temperature range. Observation found the meal served to Resident #78 consisted of Swedish meatballs, pasta, beets, peaches, and milk. Review of Resident #78's tray card, which lay beside the plate on her tray, disclosed two (2) items listed under ""dislikes"" - beets and green beans. According to assessment information provided by the facility, Resident #78 was not able to participate in an interview due to cognitive impairment. Her food was pureed, and she was fed by staff. She would not have been able to request a substitute for the beets. The dietary manager, who was present at the time of this observation at 6:00 p.m. on 10/17/10, verified that beets were listed as a dislike on this resident's tray card. A new tray was requested for this resident following the testing of her tray. .",2014-02-01
11467,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-10-19,356,C,,,SHO311,". Based on observation and staff interview, the facility failed to post - accurately and at the beginning of each shift - the required information to identify the staff members providing care and the census of the facility. Observation, on 10/17/10 at 3:40 p.m., found the posted nurse staffing information was dated 10/16/10, and the census information was absent. This practice has the potential to affect all residents and visitors. Facility census: 118 Findings include: a) Observation of the facility's posted nursing staffing data, on 10/17/10 at 3:40 p.m., found the posting was dated 10/16/10. The only nursing staffing data recorded on this posting was for the day shift of 10/16/10, and there was no resident census information recorded as required. An interview with the charge nurse (Employee #49), on 10/17/10 at 3:40 p.m., confirmed this information had not been updated to reflect the numbers of nursing staff or residents currently in the building.",2014-02-01
11468,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-10-19,280,D,,,SHO311,". Based on observation, staff interview, and medical record review, the facility failed to revise the nutrition care plan and Kardex used by nursing assistants caring for Resident #50 to accurately reflect the services to be furnished to the resident following a significant change in the resident's status, after she received a fracture to the right arm and became totally dependent on staff for eating. This was true for one (1) of four (4) sampled residents. Resident identifier: #50. Facility census: 118. Findings include: a) Resident #50 Observation of the evening meal, on 10/17/10 at 6:00 p.m., found Resident #50 being fed by a family member. Resident #50's right arm was in a sling, and she was not moving her arm. A second observation of this resident, in the dining room during the noon meal on 10/18/10, found her being fed by a nursing assistant; the resident was totally dependent on staff for eating and drinking. She was not initiating any movement of her right arm to participate in the task of eating. In an interview with the nursing assistant providing care to Resident #50 (Employee #26) on 10/19/10 at 10:00 a.m., Employee #26 was questioned about the amount of assistance Resident #50 required with meals. Employee #26 stated the resident could not move her right arm and she required total assistance with meals. Review of Resident #50's medical record disclosed a significant change in status minimum data set (MDS) was completed on 09/27/10. According to this assessment, the resident was totally dependent on one (1) staff member for eating. Review of her current care plan found the resident's nutrition plan was not reviewed or revised following her change in condition. The interventions listed for maintaining the resident's weight still stated, ""Assist resident with meals to extent needed."" It was not specific to the amount of staff assistance she needed with eating. This approach was written on 04/27/10, and was reviewed on 07/16/10, but it was not revised after the resident's significant change assessment on 09/27/10. Further review of the care plan found Resident #50's self-care deficit plan was revised on 09/28/10, to state she required total assistance from one (1) staff member with locomotion, eating, bathing, and personal hygiene. When questioned on 10/19/10 at 10:00 a.m. about how staff knows how much assistance a resident needs according to her/his care plan, Employee #26 said there was an ADL (activity of daily living) sheet that describes each resident's needs. The ADL sheet (Kardex) for Resident #50, when reviewed, found the resident was identified as being ""independent with set-up help only"" with eating. There was no evidence Resident #50's Kardex (the means by which the facility communicated elements of the care plan to direct care staff for each resident) had been updated to reflect a significant change in the resident's self-feeding ability.",2014-02-01
11469,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2010-10-07,318,D,,,UP4G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and medical record review, the facility failed to ensure one (1) of four (4) sampled residents, who had limited range of motion (ROM) of the left hand, received appropriate treatment and services to prevent further decrease in ROM. Resident identifier: #134. Facility census: 140. Findings include: a) Resident #134 Review of the resident's medical record did not find any evidence that a brace was supposed to be put on the resident. Observations made on 10/06/10, during the day at 9:00 a.m., 12:00 p.m. and 2:00 p.m., did not find evidence of a brace on the resident's left hand and wrist. On 10/07/10, a brace was found on the resident's left hand at 10:25 a.m., and the nursing assistant (NA - Employee #17) was in the room providing care for the resident, when interviewed, stated he did not care for the resident on a regular basis and did not know about the splint. A licensed practical nurse (LPN - Employee #132) who provided care for the resident, when interviewed at 10:30 a.m. on 10/07/10, said she thought therapy was supposed to get the resident a new brace, but she was not sure if it had been ordered yet. At 11:00 a.m. on 10/07/10, the interim director of nursing (DON) reported the resident was ""on the therapy board"" but, due to issues with payment, therapy was only doing evaluations for her. Interview with the assessment nurse, on 10/07/10 at 1:30 p.m., found the resident did not have a care plan for a splint, as there was no physician's order for one. Interview the rehab program director (Employee #105), at 1:45 p.m. on 10/07/10, found she did not start here until July 2010 and did not know about any issues regarding this resident. Employee #105 later said the rehab program was going to pick up the resident again and try to do some therapy for her. At 2:10 p.m. on 10/07/10, the occupational therapist (OT - Employee #162) said a new brace with finger separators would be ordered for the resident, and she would set up a splinting schedule with training for the resident's family and staff. She also reported she performed a new evaluation of the resident on 10/07/10, compared it to an OT evaluation that was completed on 05/06/10, and found the resident had not lost any ROM in that hand. A review of the resident's comprehensive annual assessment, with an assessment reference date (ARD) of 05/12/10, found in Section G the resident had limited ROM of one (1) hand with full loss of voluntary movement. In Section S, the assessor noted the resident's left hand had a contracture. Review of the resident assessment protocol (RAP) for activities of daily living / functional rehabilitation potential, dated 05/19/10, found it did not address the resident's contracture. Review of the resident's current care plan, with a created date of 03/19/10, confirmed the interdisciplinary team identified the resident was at risk for loss of ROM ""r/t (related) to existing contractures of her left hand and ankle, but the care plan did not include an intervention to apply a splinting device to the resident's left hand. Review of the OT Evaluation, with a signature date of 05/11/10, noted, ""... Pt is @ (arrow pointing up) risk for contractures & presenting /c (with) (arrow pointing down) PROM (passive range of motion) in (L) UE (left upper extremity) (symbol for 'secondary to') [MEDICAL CONDITION]/[MEDICAL CONDITION] Dx ([DIAGNOSES REDACTED]. Pt would benefit from skilled OT services for contracture Mgt (management) programs (illegible) splinting, positioning & staff education for (L) UE."" found the resident to have 0-70 degree ROM in the left wrist and she was at high risk of developing a contracture due to a [DIAGNOSES REDACTED]. A request was made of Employee #105, on the afternoon of 10/07/10, for any other information about the resident's therapy plan; Employee #105 reported the only information she had was on the resident's medical record. Review of the resident's medical record found a form titled ""Rehabilitation Screening"", dated 04/01/10, with an entry by Physical Therapy which stated; ""Pt (patient) not appropriate for contracture management program due to poor rehab potential for functional outcome."" Review of an OT Rehabilitation Summary, dated 06/08/10, noted the resident was being discontinued from OT, stating, ""Pt participated in all tx (therapy) sessions and has met all LTG's (long-term goals) @ this time. Pt is currently utilizing a resting hand splint on (L) hand to assist /c positioning (in order to (arrow pointing down) risk of further contracture). ..."" The author of this entry further noted staff and family were educated on the resident's splint schedule, and the resident was to receive passive ROM before having the splint applied. Review of the 10/07/10 OT Evaluation found the long-term goal for the resident was: ""Pt to tolerate WHO (wrist-hand orthotic) /c out complaints of skin irritation / breakdown to prevent further deformity and management of (L) UE contractures."" Treatment approaches included: ""Splint Evaluation, Splint training, and Contracture management.""",2014-02-01
11470,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2010-10-07,312,D,,,UP4G11,". Based on observation, resident interview, staff interview, and medical record review, the facility failed to ensure staff provided necessary assistance to maintain good grooming and personal hygiene for (1) of four (4) sampled residents who was unable to do so for herself. Resident #134 did not always receive mouth care, which she was unable to do for herself. The resident expressed that she would like to get out of bed for short periods of time but was not able to get out of bed by herself and was not gotten up by staff. Resident identifier: #134. Facility census: 140. Findings include: a) Resident #134 1. Observations made with a licensed practical nurse (LPN - Employee #132) and a nursing assistant (NA - Employee #17), on 10/07/10 at 10:30 a.m., found the resident's teeth had food debris on them. The resident, when interviewed, reported she had not received mouth care that day or on other days on a regular basis. She stated she had her own teeth and said she had to ask staff to clean her teeth, in order to get them taken care of. The NA reported he cleaned her teeth whenever she asked him to. The resident was observed again with the interim director of nursing (DON) at 11:00 a.m. on 10/07/10. Review of the resident's care plan, dated 06/22/09, found the resident was to be assisted with oral care as needed. - 2. Observation of the resident, on 10/06/10 at 9:00 a.m., 12:00 p.m., and 2:00 p.m. and on 10/07/10 at 10:30 a.m., found the resident in bed. When interviewed on 10/07/10 at 11:00 a.m., Resident #134 reported she would like to get up, but when she did, she often was left up too long (several hours) in the geri chair and it became uncomfortable for her. She said she would be willing to get out of bed for one (1) hour at a time, if staff would put her back to bed in a timely manner. The interim DON was present for this interview. Employee #132 (LPN), when interviewed on 10/07/01 at 10:30 a.m. during an earlier observation of the resident, reported the resident would get up for showers, to get her hair done, and to get her bed made. Review of the care plan, dated 06/02/09, found the resident would be encouraged assisted to change positions frequently and transferred with a mechanical lift using a two (2) person assist. The activities care plan note, dated 08/12/10, stated, ""Resident requires max assist w/ (with) activity intervention d/t (due to) impaired mobility. Her participation has decreased this review period due to episodes of not feeling well... Resident will attend large group activities... Her husband visits daily and stays for extended periods, as well as visits from her daughter. No sign change."" .",2014-02-01
11471,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-10-04,166,D,,,PYV111,". Based on a review of the resident council minutes, medical record review, resident interview, family interview, and staff interview, the facility did not ensure all complaints made by residents, families, or responsible parties were documented and investigated. In addition, the facility did not follow up with those individuals making the complaints, to let them know the outcome of the complaint investigation and the resolution to the issue. Resident identifier: #66. Facility census: 120. Findings include: a) Resident #66 During tour of the facility on 10/03/10, a family interview revealed Resident #66 had experienced some problems with having to sit in a soiled brief for a long period of time. The resident had wanted to attend a church service but had to wait for a long time before she could go, because staff was not available to change her soiled brief. On 10/04/10 at approximately 9:00 a.m., telephone contact with Resident #66's family revealed this incident took place in September 2010. The family member indicated there were problems with getting assistance from nurse aides on the last two (2) Sundays in September. The family member reported nurse aides told her they could not assist in changing Resident #66's brief until the lunch trays were picked up. The family member related that, on 09/19/10, she had complained to staff but did not put her complaint in writing. On 09/26/10, she did write a letter listing her concerns about staff not assisting Resident #66 with incontinence care. The family member put the letter under the administrator's door. The administrator confirmed this did occur and that he passed the letter along to Employee #50, the unit manager on the hall where Resident #66 lives. In an interview on 10/04/10 at approximately 11:00 a.m., Employee #50 (registered nurse unit manager) confirmed she had received this letter from the administrator. She said she investigated the family's concerns. The outcome of the investigation did reveal a nurse aide had told the family member she could not assist in changing Resident #66's brief until she finished picking up lunch trays. Employee #50 could not remember the name of this particular nurse aide. She did say she had instructed this individual to always assist a resident if they needed something done, even if they were in the process of picking up trays. Employee #50 did not have any documentation about this incident. There was no evidence of any education that had taken place with the nurse aide involved. Also, there was no evidence that the facility had contacted the family member to let them know the outcome of the investigation. On 10/04/10 at approximately 12:00 p.m., Resident #66 said she did have to wait for long periods of time on occasion to get her brief changed. She said, recently, the wait time had been reduced to twenty (20) minutes. The administrator agreed this resident needed to know what had occurred in regards to the investigation about her concerns with her brief not changed timely. He confirmed that, up to this point, that had not taken place. On 10/04/10 at approximately 12:45 p.m., review of the resident council minutes from 09/21/10 revealed the council members expressed concerns regarding call lights not being answered timely on Cherry hall. The activity director (Employee #80) indicated she had not passed this information from the council along to the unit manager of Cherry hall. The administrator agreed this information needed to passed along in a timely manner and that it had not occurred.",2014-02-01
11472,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-10-21,253,D,,,6HW411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, family interview, and staff interview, the facility failed to clean the floor adequately for one (1) of eight (8) sampled residents. Numerous observations of the resident's floor found it to be sticky, even after having been recently mopped. This stickiness had the potential to affect the steadiness of the gait of the resident who was known to ambulate within the room independently; it also compromised safety of others, as it had the potential to harbor bacteria that could be transmitted throughout the facility on the soles of shoes of all staff who entered the room. Resident identifier: #61. Facility census: 120. Findings include: a) Resident #61 Record review revealed Resident #61's [DIAGNOSES REDACTED]. During interview with the nurse unit manager (Employee #51) on 10/19/10 at 4:30 p.m., she said Resident #61's physician orders [REDACTED]. Resident #61 experienced a fall in early October, but x-rays completed af the emergency room ruled out any new fractures; she was wearing hipsters at the time of the fall. Currently, she was on the waiting list for inpatient care at a behavioral health / medicine center related to problem behaviors that were not able to successfully be redirected. Observation of the resident throughout the survey found she walked in her room independently, ambulated to the toilet independently, and was observed closing the door to the hallway on more than one (1) occasion. Observation of the resident's floor, on 10/18/10 at 3:00 p.m., revealed the floor was sticky in a wide area around all sides of the bed. The sticky floor was also observed by the life-safety code (LSC) surveyor who brought it to the attention of Employee #133 (the environmental service director), who immediately called staff to mop the floor. Observation, on 10/18/10 at 5:30 p.m., found the floor had dried and was just as sticky as it had been previously. Observation of the floor, on 10/19/10 at 9:00 a.m., found the floor to be sticky all around the bed. This was called to the attention of the LSC surveyor, who again notified the environmental service director, who again called staff to mop the floor. After drying, the floor remained sticky in places. During an interview on 10/19/10 at approximately 11:00 a.m., Employee #133 said numerous members of the housekeeping staff had been out of medical leave in recent times, which had cut down their daily number of traditional full-time housekeeping staff on duty. Observation of the floor in Resident #61's room, on 10/20/10 at 9:05 a.m., found the floor to be sticky in one (1) small area, but this was an improvement over observations made on the preceding two (2) days. Review of recent resident / family grievances found one dated 09/30/10, related to the sanitation of Resident #51's room. During a telephone interview with this family member on 10/18/10 at 7:00 p.m., she acknowledged the room had been cleaned the week of her request, but she had issues with the cleanliness of the room during the following week, as it related to allegedly finding mouse droppings on the floor on 10/07/10. She said she found Resident #51's floor sticky on the left side of the bed where staff sat while feeding him. Review of recent resident / family grievances found one dated 09/22/10 from Resident #27, who complained his room was not cleaned even when housekeeping staff was asked by the resident to do so. This grievance was followed up by the facility. Review of the resolution portion of the grievance found a note that, on 10/03/10, housekeeping again did not clean his room. Review of recent resident / family grievances found one dated 09/23/10, where Resident #117's family member complained the resident's room was ""filthy ... mopped but not swept"". Facility's resolution included having the room deep cleaned 10/05/10, with follow-up contact with the family. Review of the 09/21/10 Resident Council meeting minutes found three (3) residents (names not identified) complained of housekeeping staff not cleaning their room adequately. During an interview with the administrator on 10/19/10 at approximately 10:00 a.m., he said the facility, in recent weeks, had adopted a different mopping product for a trial on a couple halls which included the 200 hall where Resident #61 resided. When informed of the persistent stickiness of the floor in Resident #61's room even after mopping, he said it was probably time to complete an evaluation of the product change. .",2014-02-01
11473,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-10-21,309,D,,,6HW411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, medical record review, and staff interview, the facility failed to monitor the effectiveness of treatment after administration of Tylenol for a new development of fever and in the presence of other symptoms and complaints; the facility also failed to monitor the temperature of a dependent resident with a history of repeated urinary tract infections after a new onset of fever early in the morning. This was evident for one (1) of six (6) sampled residents. Resident identifier: #51. Facility census: 120. Findings include: a) Resident #51 During an interview via telephone on 10/18/10, Resident #51's family member stated that, on 01/10/10 Resident #51 developed a high fever and was medicated with a fever-reducing medication, and five (5) hours elapsed before his temperature was re-checked by staff. By this time, he was totally unresponsive and the fever had elevated even more. Subsequently, he was transported to the hospital for a twelve (12) day stay. Upon his return to the facility, the pressure ulcer on his coccyx had worsened to a Stage IV wound, and he required a wound VAC after the area was surgically debrided during the hospitalization . Medical record review revealed Resident #51's temperature was 100.9 degrees Fahrenheit (F) on 01/10/10 at 3:30 p.m., and he was medicated with [MEDICATION NAME]. The physician was notified, and new orders were received for a urinalysis and culture to be obtained the following day. Further medical record review revealed that, at 5:30 p.m. on 01/01/10, he refused dinner and complained of not feeling well. The nurse documented his refusal to go to the emergency room . There was no evidence that his temperature was monitored at this time, to ascertain whether the [MEDICATION NAME] was effective in reducing his temperature, and there was not evidence to reflect the family was notified of the fever. It was not until 8:00 p.m. on 01/01/10 that the nurse again assessed him again; she documented his temperature had risen to 104.7 degrees F and he was ""non-responsive"" and had no ""appropriate pain response"". He was medicated with Tylenol per standing order for fever and was transferred to the emergency room at 8:30 p.m., where he was admitted and subsequently spent the following twelve (12) days. During an interview with the interim director of nursing (DON) on 10/19/10 at approximately 4:00 p.m., she said there was no policy regarding reassessing a resident's temperature after he/she was identified as having a new onset of fever; rather, it was left to the nurse's discretion. Per request, the DON and a medical records staff member (Employee #50) said they would try to locate and copy any documentation that could be found in addition to the nursing notes for 01/10/10 which gave evidence of temperature assessments within that five (5) hour time frame. However, none was produced. Observation, on 10/20/10 at 9:00 a.m., found Resident #51 was not in the facility. Staff interview found he was sent to the emergency room this morning around 8:00 a.m. Record review, on 10/21/10, revealed a nursing note dated 10/19/10 at 5:57 a.m., documenting the resident had a temperature at 101.4 degrees F and was medicated with Tylenol 650 mg every ""4 hours PRN (as needed) up to 3 doses. If temp (temperature) persists call MD (medical doctor)."" Record review revealed his temperature was checked once again at 9:00 a.m. on 10/19/10 and was afebrile at 98.5 degrees. Further record review revealed no evidence that his temperature was assessed again until the following morning, twenty-one (21) hours later, on 10/20/10 at 6:12 a.m., when it was found to be 103.1 degrees F. He was medicated with Tylenol, and the physician was paged. At 8:10 a.m. on 10/20/10, the nurse recorded the resident ""remains confused & lethargic. Temp. 102.1"", and orders had been received to send him to the emergency room for evaluation and treatment. Record review found he was transferred to the emergency room at 8:28 a.m., and returned to the facility on [DATE] at 12:59 a.m., with a [DIAGNOSES REDACTED]. During an interview with the nurse unit manager (Employee #51) on 10/21/10 at 10:00 a.m., she was unable to produce evidence that this resident's temperature had been assessed with [REDACTED]. She stated the nurse from day shift yesterday (10/19/10) may have forgotten to record a temperature assessment, as well as the 7:00 p.m. to 7:00 a.m. She also said the new onset of fever for Resident #51 had not been noted on a 24-hour shift report.",2014-02-01
11474,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-12-09,328,D,,,6HW412,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, staff interview, medical record review, and policy review, the facility failed to ensure one (1) of ten (10) sampled residents received the maximum benefit of each aerosolized treatment ordered by her physician. Resident #111, whose [DIAGNOSES REDACTED]. She had a physician's order permitting her to self-administer the aerosolized treatments; however, there was no evidence the interdisciplinary team completed an assessment to ensure the resident was capable of reliably self-administering these treatments, and this self-administration of aerosolized medications was not addressed on her care plan. Licensed nursing staff was aware Resident #111 did not self-administer these treatments in an effective manner, and they did not provide additional monitoring / supervision to ensure she received the maximum benefit of each treatment. Additionally, licensed nursing staff did not complete pre- and post-treatment assessments that would allow them to determine whether the treatments were effective. Resident identifier: #111. Facility census: 113. Findings include: a) Resident #111 1. Observation, during tour on 12/06/10 at 2:10 p.m., found Resident #111 sitting in her room holding a medicine cup attached to a nebulizer. The medicine cup had a small amount of liquid in it. The resident stated she needed her breathing treatment set up, that she was supposed to have received it at 1:00 p.m. The resident stated she asked both a nursing assistant and her nurse (Employee #21, a licensed practical nurse - LPN) for the treatment. In an interview on 12/06/10 at 2:15 p.m., Employee #21 said she set up the treatment for [REDACTED]. She reported the resident does the treatment herself after the nurse sets up the treatment, which includes putting the medication into the medicine cup. The resident then hits the button to turn on the machine when she is ready and self administers the treatment. The nurse then accessed the medication cart and took out Atrovent and [MEDICATION NAME] and went to the resident's room to set up the medication for Resident #111. -- 2. A physician's order, dated 11/23/10, stated, ""Res (resident) may administer [MEDICATION NAME] / Atrovent treatments herself."" An earlier order, dated 08/05/10, stated the resident was to receive Atrovent 2% Inhaler, one (1) unit dose every four (4) hours administered via nebulizer, give with [MEDICATION NAME]; and [MEDICATION NAME] 0.083%, one (1) unit dose every four (4) hours administered via nebulizer, give with Atrovent. Review of the resident's December 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -- 3. Review of the resident's minimum data set assessment (MDS) history, beginning with an MDS dated [DATE] and continuing through the most recent MDS dated [DATE], revealed the resident was identified as being unable to self-medicate. Review of the resident's medical record failed to find evidence the resident was assessed for the ability to self-medicate. Review of the resident's care plan, dated 10/26/08 and revised on 09/30/10, found the resident was identified as ""Exhibiting or is at risk for complications related to [MEDICAL CONDITION]"", but there was no mention of the resident having been identified by the interdisciplinary team as being able to self-administer medications, and her care plan was not revised to address the self-administration of her aerosolized breathing treatments after the physician's order was written to permit this on 11/23/10. -- 4. The resident, when interviewed again on 12/06/10 at 4:15 p.m., reported she did not receive her 5:00 a.m. nebulizer treatment either. She said that, when the nurse set up the nebulizer, she was smoking and when she returned from smoking, most of the medication in the cup to the nebulizer had drained from the cup. She tried to utilize the medication remaining in the cup and it was not effective. She stated that, when this happens, she becomes short of breath. -- 5. A subsequent interview with Employee #21, on 12/06/10 at 4:30 p.m., found the resident's next scheduled nebulizer treatment was due at 5:00 p.m., but she would wait until 5:45 p.m. before administering the next treatment. This would only allow two (2) hours and forty five (45) minutes between treatments. Employee #21, when asked if the nurse on the night shift had reported to her that Resident #111 did not receive an effective treatment at 5:00 a.m., responded that she did not. The nurse reported that she marks the treatment as given on the MAR indicated [REDACTED]. The nurse stated she did not assess the resident's heart rate, respiratory rate, and breath sounds prior to initiating a treatment and after each treatment was finished. -- 6. Review of the facility's policy titled ""2.12 Medications: Self Administration"" (effective 06/01/96 and revised 01/01/04) revealed the following, ""Process: ""1. When a customer requests medication self administration, initiate the process to assess customer's capability. The customer must meet the follow criteria. ""1.1. Be able to demonstrate: ""1.1.1. Knowledge of medications and medication schedule ""1.1.2. Self-administration including use of packaging, reading label, open containers; and ""1.1.3. Ability to administer medications properly, e.g., insulin / syringe, eye drops, inhalers as needed. ""2. If assessment indicates customer is capable of medication self-administration, notify physician to obtain order. ""3. Address medication self-administration in customer's care plan. Include plan for: ""3.1. Storage, location of medications, and documentation of medication administration; ""3.2. Education for customer / family regarding medication self-administration process, specific medication information and safe, effective use of medications, and ""3.3. Ongoing monitoring and reassessing of customer's capacity. ""4. Securing medications at the nursing station. Keep a limited quantity in a locked drawer at customer's bedside. Assure that customer and nursing both have a key. ""5. Instruct customer in medication self-administration procedure. Include: ""5.1. Obtaining medication ""5.2. Administering medication according to physician order; ""5.3. Recording administration on documentation record. ""6. Monitor customer to assure medication is administered as ordered and for effectiveness and/or side effects of medication. ""6.1. Notify physician of any side effects of changes in condition that may require medication adjustment. ""6.2. Notify physician and care plan team if customer demonstrates decrease in capability for medication self-administration. ""7. Adjust plan for medication self-administration as indicated. ""8. Document: ""8.1. Customer's request and assessment of capability in Nurses' Notes or progress notes; ""8.2. Plan for storage, location, documentation, education, and monitoring on customer's care plan; ""8.3. Ongoing monitoring of customer's capability in Nurses' Notes."" -- 7. Review of the ""Assessment for Self-Administration of Medications"" (dated 1992), found the following instructions: ""Before performing this assessment, verify that there is a physician order in the resident's chart for self-administration of the specific medication under consideration and that the resident has signed the appropriate document stating the desire to self-administer his/her own medication. Proceed by checking the appropriate response below for each of the 19 items listed. The resident must be able to perform each step indicated below prior to beginning self-administration of medications. The interdisciplinary team will be responsible for approving self-medication using the assessment as a guide."" Item #19 of the assessment asked, ""Can administer inhalant medication with proper procedure?"" -- 8. Review of the resident's MAR found the form used for documenting self-administration of medications titled ""Self Medication Administration Record"" was not utilized. -- 9. Review of the facility policy titled ""11.21 Small Volume Nebulizer"" (dated 01/01/04 and revised 06/01/04), revealed at Item #8, before a nurse administered medications utilizing a nebulizer, the nurse was supposed to: ""Assess the patient's heart rate, respiratory rate, and breath sound prior to initiating treatment."" Item #20 stated, ""Upon completion of the treatment, check patient's heart rate, respiratory rate, and breath sounds."" -- 10. On 12/07/10 at 10:00 a.m., the interim director of nursing was interviewed and additional information was requested. As of exit on 12/09/10 at 12:00 p.m., no additional information was provided with respect to the above concerns. .",2014-02-01
11475,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-12-09,280,D,,,6HW412,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, staff interview, medical record review, and policy review, the facility failed, for one (1) of ten (10) sampled residents, to revise the resident's care plan to address her self-administration of aerosolized medications after an order was received from her physician to permit this. Resident #111, whose [DIAGNOSES REDACTED]. She had a physician's orders [REDACTED]. Resident identifier: #111. Facility census: 113. Findings include: a) Resident #111 1. Observation, during tour on 12/06/10 at 2:10 p.m., found Resident #111 sitting in her room holding a medicine cup attached to a nebulizer. The medicine cup had a small amount of liquid in it. The resident stated she needed her breathing treatment set up, that she was supposed to have received it at 1:00 p.m. The resident stated she asked both a nursing assistant and her nurse (Employee #21, a licensed practical nurse - LPN) for the treatment. In an interview on 12/06/10 at 2:15 p.m., Employee #21 said she set up the treatment for [REDACTED]. She reported the resident does the treatment herself after the nurse sets up the treatment, which includes putting the medication into the medicine cup. The resident then hits the button to turn on the machine when she is ready and self administers the treatment. The nurse then accessed the medication cart and took out Atrovent and [MEDICATION NAME] and went to the resident's room to set up the medication for Resident #111. -- 2. A physician's orders [REDACTED]."" An earlier order, dated 08/05/10, stated the resident was to receive Atrovent 2% Inhaler, one (1) unit dose every four (4) hours administered via nebulizer, give with [MEDICATION NAME]; and [MEDICATION NAME] 0.083%, one (1) unit dose every four (4) hours administered via nebulizer, give with Atrovent. Review of the resident's December 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -- 3. Review of the resident's care plan, dated 10/26/08 and revised on 09/30/10, found the resident was identified as ""Exhibiting or is at risk for complications related to [MEDICAL CONDITION]"", but there was no mention of the resident having been identified by the interdisciplinary team as being able to self-administer medications, and her care plan was not revised to address the self-administration of her aerosolized breathing treatments after the physician's orders [REDACTED]. -- 4. Review of the facility's policy titled ""2.12 Medications: Self Administration"" (effective 06/01/96 and revised 01/01/04) revealed the following under the heading ""Process"": ""3. Address medication self-administration in customer's care plan. Include plan for: ""3.1. Storage, location of medications, and documentation of medication administration; ""3.2. Education for customer / family regarding medication self-administration process, specific medication information and safe, effective use of medications, and ""3.3. Ongoing monitoring and reassessing of customer's capacity. .",2014-02-01
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
11477,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2010-10-14,280,D,,,LTYG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the care plan of one (1) of four (4) sampled residents was revised to reflect the resident's current problems and needs. The lack of an updated care plan resulted in a lack of goals and interventions to address the most current issues facing the resident. The facility had relocated the resident to a different area of the building in a room by himself, and the care plan failed to address this change in environment and the potential negative impact it could have on the resident. Resident identifier: #28. Facility census: 86. Findings include: a) Resident #28 Record review revealed a social work progress note documenting Resident #28's move to a room on second floor on 09/02/10, due to safety concerns surrounding his aggressive behaviors towards other residents. The resident had spent approximately ten (10) days in an inpatient acute psychiatric hospital from 08/03/10 through 08/13/10, due to increased aggressive behaviors. On 09/02/10, the facility moved Resident #28 to a semi-private room without a roommate on second floor, in order to ensure the safety of other residents and to monitor Resident #28's behavior. The facility also placed an alarm on a gate across the doorway which would sound when the resident came in and out of his room during the night time hours. Resident #28 came to the facility in February 2008. He had lived in a room on first floor with two (2) other roommates for over two (2) years. Due to his increased negative behaviors and the guardian's lack of acceptance of alternatives to promote the safety of the roommates (such as the use of a bed alarm on Resident #28 to alert staff when he was transferring out of bed), the facility elected to move the resident to ensure safety of others and to monitor for further agitation and negative behaviors. After the resident went to live on second floor, the facility failed to revised his care plan to address adjustment issues this resident faced. Resident #28 had [DIAGNOSES REDACTED]. He received [MEDICATION NAME] 0.5 mg twice a day for anxiety / agitation. He also received [MEDICATION NAME] 50 mg once a day for depression, as well as Mirtazepine ([MEDICATION NAME])[MEDICATION NAME](orally disintegrating tablets) 15 mg once a day at bedtime for depression. The care plan addressed specifics as to how the facility would monitor the resident's behavior to protect and ensure the safety of others. However, it failed to address the resident's relocation to a new environment and associated adjustment difficulties, especially in view of his pre-existing [DIAGNOSES REDACTED]. On 10/13/10, medical record review for Resident #28 revealed nursing staff had observed the resident talking to himself in his room on or near 09/29/10. The staff member identified this as a new behavior. Another staff member overheard the resident threatening to harm an incapacitated resident on 09/27/10. On 10/14/10 at approximately 4:00 p.m., the administrator and director of nursing confirmed the facility's interdisciplinary team had not addressed in the care plan how the move would impact the resident's psychosocial well-being. They agreed this was a significant life-changing event for someone with dementia, anxiety, and depression. They also agreed the care plan should have revised with goals, and interventions to assist the resident in reaching the goals, to promote the resident's highest practicable level of well-being.",2014-02-01
11478,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2010-10-06,285,D,,,4XPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and review of the WV Medicaid program manual for nursing facilities, the facility failed to coordinate their assessments with the preadmission screening and resident review (PASRR) program under Medicaid as required. The facility readmitted a resident from an inpatient psychiatric stay prior to receiving approval by the State-designated reviewing agency - West Virginia Medical Institute (WVMI), which resulted in the resident having no payer source to cover his continued stay at the facility when it was determined by WVMI that he was no longer medical eligible for nursing home placement under WV Medicaid criteria. Resident identifier: #56. Facility census: 112. Findings include: a) Resident #56 Record review revealed Resident #56 came to the facility on [DATE] with a pre-admission screening form (PAS-2000) signed by the physician on 01/18/10, who indicated his primary [DIAGNOSES REDACTED]. This PAS-2000 was reviewed by WVMI on 01/20/10, at which time the reviewer determined Resident #56 was medically eligible, under the WV Medicaid criteria, for nursing facility services and that a Level II evaluation was necessary. A Level II evaluator determined Resident #56 did not require specialized services for mental illness or mental [MEDICAL CONDITION] on 01/22/10. Resident #56's initial PAS-2000 indicated he was appropriate for nursing home placement for a period of up to six (6) months, after which another PAS-2000 would have to be completed for his nursing home stay to continue to be paid for by WV Medicaid. During this six-month period, Resident #56 was admitted for inpatient psychiatric services from 05/28/10 until 06/09/10, when he was readmitted to the nursing home. A second PAS-2000, signed by a physician on 06/15/10, indicated Resident #56 needed nursing home services and was not likely to eventually return home. On 06/17/10, a reviewer from WVMI denied the request for nursing home admission for Resident #56, stating he was ""ineligible for long-term care (nursing home) admission based upon WV Medicaid criteria."" This determination was made after Resident #56 had already been readmitted to the nursing facility, which resulted in the resident having no payer source to pay for his continued stay in the nursing home. In an interview on 10/06/10 at approximately 2:30 p.m., the social worker (Employee #1), director of nursing (Employee #2), and administrator (Employee #3) all indicated they did not know the resident needed an approved PAS-2000 prior to his readmission at the facility from an inpatient psychiatric stay. The nursing facility manual, Chapter 514 Section - 514.8.2 states: ""To qualify medically for the nursing facility Medicaid benefit, an individual must need direct nursing care twenty-four (24) hours a day, seven (7) days a week. The Bureau has designated a tool known as the Pre-Admission Screening form (PAS) to be utilized for physician certification of the medical needs of individuals applying for Medicaid benefit .... ""Each nursing facility must have an original pre-admission screening tool to qualify the individual for Medicaid and to meet the federal PASRR requirements. Should the receiving nursing facility fail to obtain an approved assessment prior to admission of a Medicaid eligible individual, the Medicaid program cannot pay for services. The individual cannot be charged for the cost of care during this non-covered period. ""A Medicaid recipient who converts from Medicare Part A coverage to Medicaid does not need a new assessment to receive the Medicaid benefit. Medicaid coverage can be reinstated as long as a Medicaid denial letter has been issued. ""A new medical assessment must be done for Medicaid eligibility for the nursing facility resident for all of the following situations: ""- Application for the Medicaid nursing facility benefit; ""- Transfer from one nursing facility to another; ""- Previous resident returning from any setting other than an acute care hospital; ""- Resident transferred to an acute care hospital, then to a distinct skilled nursing unit, and then returns to the original nursing facility; and ""- Resident converts from private pay to Medicaid."" As Resident #56 was returning from a setting other than an acute care hospital, a new PAS-2000 was required prior to his re-admission to the nursing facility.",2014-02-01
11479,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,278,B,,,UFEY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of minimum data set (MDS) assessments, and staff interview, the facility failed to accurately document assessment data on the MDS relative to pressure ulcers, infections, and toileting plans for four (4) of twenty (20) sampled residents. Resident identifiers: #65, #3, #4, and #81. Facility census: 113. Findings include: a) Resident #65 Record review (on 01/06/09) revealed the resident had a Stage II pressure ulcer to the coccyx which was recorded as being healed on 12/02/08. This information was noted on the December 2008 treatment administration record and a nurse's note dated 12/02/08. A skin assessment, dated 12/20/08, recorded no pressure ulcer(s) present at that time. Review of the resident's MDS, with an assessment reference date (ARD) of 12/24/08, found the assessor recorded in Section M1 the resident had one (1) Stage II ulcer. The MDS nurse (Employee #23) was interviewed on 01/07/09 about the information coded in Section M1 of the MDS. After reviewing the issue, she verified the MDS was coded incorrectly. On 01/08/09 at 11:05 a.m., the MDS nurse provided a copy of a corrected MDS, with an ARD of 12/24/08. In Section M1, the assessor documented no pressure ulcer(s). b) Resident #31 Review (on 01/07/09) of the admission MDS, completed on 12/24/08, revealed the assessor indicated, in Section I2, the resident had an antibiotic-resistant infection. Interview with the director of nursing (DON - Employee #2), at about 6:00 p.m. on 01/07/09, and review of the laboratory reports confirmed that, when the resident was admitted on [DATE], the resident had a [DIAGNOSES REDACTED]. c) Resident #40 Review (on 01/06/09) of the quarterly MDS, completed on 11/12/08, revealed the assessor indicated the resident was non-ambulatory and incontinent of bladder. In addition, the assessor marked Item H3a to indicate the resident was on a scheduled toileting plan. Interview with a nursing assistant (Employee #63), on 01/06/09 at 1:05 p.m., confirmed the resident was not on a toileting plan but was checked regularly for bladder incontinence. d) Resident #81 Review (on 01/06/09) of the quarterly MDS, completed on 11/23/08, revealed the assessor indicated the resident was non-ambulatory and incontinent of bladder. In addition, the assessor marked Item H3a to indicate the resident was on a scheduled toileting plan. Interview with a nursing assistant (Employee #63), on 01/06/09 at about 1:00 p.m., confirmed the resident was not on a toileting plan. .",2014-02-01
11480,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,279,E,,,UFEY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to develop individualized comprehensive care plans for each resident to include services / treatments to be provided and appropriate interventions to assist with achievement of established goals. Care plans were not developed and individualized to reflect the actual care and services to be provided for six (6) of twenty (20) sampled residents. Resident identifiers: #36, #10, #97, #28, #62, and #81. Facility census: 113. Findings include: a) Resident #36 Review of the interdisciplinary care plan for Resident #36, found a sixty-four (64) paged document consisting of pre-printed problems, goals, and interventions with blanks to be filled in to make the care plan individualized. The care plan was hard to follow, and it did not always accurately reflect what problems the resident was experiencing for which specific interventions were being applied. 1. This resident had a history of [REDACTED]. devices. There was a different care plan for each device. The problem statements and goals were the same for each device, and each began with the statement: ""Refer to the physical restraint / enabler assessment."" 2. The physical restraint / enabler care plan was reviewed. This care plan was dated 12/05/08. The plan did not have a problem statement, goal, or interventions to achieve the goal. The care plan simply said, ""Refer to the physical restraint / enabler assessment."" The goal associated with this problem was ""(Resident) will be free of negative effects with the use of an enabler."" This goal did not address what the resident would achieve through the use of the device, i.e., improve functioning, increased independence, etc.) Review of the interventions associated with this goal found no measures to assist the resident in achieving the stated goal. The interventions simply said to apply the enabler (a lap buddy) when in the wheelchair for poor safety awareness with frequent falls; review the enabler information sheet every ninety (90) days; refer to the Mood and Behavior Symptom Assessment plan of care (which, when reviewed, did not refer to the lap buddy in any way); refer to the falls assessment prevention and management plan of care (which did not include the lap buddy use); refer to the skin integrity assessment (which did not contain information about the lap buddy): prevention and management plan of care; maintain resident bowel and bladder routine; educate resident / family about physical restraints / enabler using the physical restraint / enabler information form (which was incomplete). The care plan for this resident's lap buddy use did not specify the problem necessitating the application of the device. Additionally, record review revealed the resident became agitated and had sustained injuries when the device was applied, and this response was not addressed in the resident's care plan. b) Resident #10 Review of the interdisciplinary care plan for Resident #10, found a fifty (50) paged document consisting of pre-printed problems, goals, and interventions with blanks to be filled in to make the care plan individualized. The care plan stated, ""Recent or chronic history of incontinence. Contributing factors included laxative use PRN and cognitive / perceptual impairment, loss of sphincter control, and decreased physical activity."" One (1) goal for problem statement was: ""Will ingest adequate fluids evidenced by resident's skin turgor."" Other goals were: ""Will have bowel movement every three days"" and ""Will be cooperative with assisted toileting."" The interventions to assist with achievement of these goals included, ""See nutritional care plan"" and ""See skin integrity prevention and management plan of care."" The stated interventions did not address the identified problem and would not lead to achievement of the established goals. c) Resident #97 1. Record review found a nursing note recording the resident requested pain medication at 10:50 a.m. on 12/18/08. The nurse noted having instructed the resident that her ""pain medications are scheduled"". There was no evidence that the nurse assessed the pain or offered her one (1) of her prescribed PRN medications for breakthrough pain. Another nursing note, dated 12/30/08 at 1:30 p.m., stated, ""Resident belligerent with staff today about her pain medicine ([MEDICATION NAME]). Resident is on pain medication around the clock, offered Tylenol in between doses, resident refused meds (Tylenol). "" Another note, dated 01/01/09 at 4:35 a.m., stated, ""Resident requested this nurse to give pain pill early, when this nurse refused resident became upset mumbled statements under her breath, and accepted her set schedule resting at this time."" A nursing note, dated 01/01/09 at 1:35 p.m., stated, ""Resident upset pain meds are on a scheduled basis instead of PRN. Attempted redirection but resident became more agitated. Continue to monitor."" There was no evidence of further monitoring in the nursing notes, and this was the last nursing note written as of 01/06/09, which was the date of this medical record review. During an interview with Resident #97 on 01/06/09 at 10:00 a.m., she identified that her scheduled pain medication was not always effective. She stated that, sometimes, the pain in her back and shoulder was severe. A review of the resident's care plan, dated 11/25/08, revealed this resident had persistent (chronic) pain with ""an alteration in comfort related to pain secondary to L (left) shoulder pain."" Pre-printed goals were checked for this problem statement as follows: ""Decrease persistent pain to a tolerated level so resident can function in daily life""; ""Resident will report pain relief within 30 - 60 minutes receiving pain medication or treatment as ordered; and ""Will have not signs and symptoms of unrelieved pain no complaints of pain when questioned, no vocalization related to pain, no non-verbal signs, verbalization of pain, no decline in activity."" Also included were the following functional goals: ""Participate in ADL's""; ""Participate in therapies""; ""Will not experience decline in functioning related to pain""; and ""Non-pharmacological measures will be used as alternatives to medication when appropriate."" The interventions for achieving the goals written above were as follows: ""Administer pain medication as ordered, Tylenol 650 mg po (by mouth), monitor and record effectiveness, side effects of medication PRN (as needed) observe and notify provider for s/s (signs / symptoms) of constipation, administer bowel care per protocol, assess for verbal and non-verbal signs and symptoms of distress or pain unrelieved by ordered treatments / medications, observe during rest and during movement for pain, [MEDICATION NAME] 50 mg po (by mouth) q4h (every four hours) PRN, [MEDICATION NAME] 5/500 ([MEDICATION NAME]) q4h PRN, position changes, encourage mobility, physical activity as tolerated to prevent stiffness / contractures, Physical therapy and Occupational therapy to evaluate and treat as ordered to improve functional states, refer to pain management clinic PRN, discuss progress toward or maintenance goals for medication therapy, review medication regimen with the provider and the pharmacist PRN."" This care plan was not individualized to address Resident #97's pain. 2. The resident's care plan also contained the following problem statement: ""Refer to the physical restraint / enabler assessment."" The goal stated: ""Will be free of negative effects with the use of an enabler."" (There was no mention about how the enabling device was intended to improve the resident's functionality.) One (1) intervention simply stated what device was to be used (1/2 top side rail) to aid in turning and reposition. The only other intervention was ""Refer to the mood and behavior symptom plan of care."" Review of the mood and behavior plan of care found no interventions related to the use of an enabler. There were no interventions written to assist in achieving the goal established. 3. The director of nursing (DON - Employee #2) was made aware of the inconsistencies in Resident #97's care plan at 10:00 a.m. on 01/08/09. She stated she was aware there were a lot of pages in the care plan, but this was the way their corporation required them to do the care plans. She was made aware that the resident's true problems often could not be identified and the treatment they were to receiving often did not match the care plans. d) Resident #28 Medical record review, on 01/06/09 at 1:32 p.m., revealed Resident #28 was on several medications for moods / behaviors, including [MEDICATION NAME] 12.5 mg via g tube BID (two-times-a-day), [MEDICATION NAME] 0.5 mg via g tube TID (three-times-a-day), and [MEDICATION NAME] 10 mg via g tube QD (every day). Review of the resident's most current care plan, dated 11/26/08, found the facility identified the resident was at risk for depression as evidence by ""unhappy behavior symptoms"" and persistent anger with self or others. The goal included reduction / elimination of unhappy behavior symptoms. Interventions to achieve the goal included: ""offer time to express feelings and concerns; separate from stressful situations; 1:1 (one on one) conversation to maintain trust of staff; offer reassurance; and depression scale q3 (every three) months."" Another problem was behavioral symptoms that may be harmful to self or others or interfere with function or care as evidence by yells out loud and grabs, combative with staff. The goal included no injury to self or others. Interventions included: ""administer medications, see nsg (nursing) mar (medication administration record), redirect to activity of 1:1 diversion, offer time to express feelings and concerns, separate from stressful situations, redirect to act. or 1:1 act (activity or one-on-one activity) offer to call son."" Review of the resident's minimum data set assessment (MDS), dated [DATE], revealed Resident #28 had short and long term memory problems and moderately impaired cognitive skills for daily decision making, and she exhibited repetitive verbalizations, repetitive anxious complaints, sad pained worried facial expressions crying and tearfulness (of which all were easily altered). Review of the behavior tracking report, from 06/01/08 through 11/30/08, found the following: - 06/17/08 - crying and ""mood persistence"" (each one time). - 07/27/08 - crying - 08/08/08 - crying and ""mood persistence"" - 08/21/08 and 08/30/08 - crying - 09/02/08 and 09/03/08 - physical abuse (a behavior which was not described) - 10/03/08 - crying - 10/04/08 - crying and ""mood persistence"" - 10/06/08 - sad / pained / worried facial expression and ""mood persistence"" - 10/07/08 - crying two (2) times and ""mood persistence"" - 10/26/08 - crying and repetitive verbal, unrealistic fears, repetitive anxious, sad / pained / worried facial expression, and ""mood persistence"" - 10/27/08 - crying and ""mood persistence"" - 11/15/08, 11/21/08, and 11/25/08 - crying and ""mood persistence"" The facility failed to develop an individualized care plan to address specifically identified behaviors exhibited by the resident based on a comprehensive assessment of factors causing or contributing to these behaviors, and failed to develop individualized, realistic interventions in recognition of this resident's limited cognitive ability and identified triggers. e) Resident #62 Medical record review, on 01/06/09 at 4:15 p.m., revealed Resident #62 received several medications for moods / behaviors. Her physician's orders [REDACTED]. - On 10/31/07 - [MEDICATION NAME] tablets 20 mg PO (by mouth) Q AM (every morning) and [MEDICATION NAME] 50 mg po BID; - On 02/20/08 - [MEDICATION NAME] 200 mg PO QD and [MEDICATION NAME] 100 mg PO QD; - On 05/15/08 - [MEDICATION NAME] 5 mg po BID; - On 11/12/08 - [MEDICATION NAME] 0.25 mg PO Q AM, [MEDICATION NAME] 0.5 mg PO Q HS (every night), and [MEDICATION NAME] ER 250 mg PO QD. Review of resident's current care plan, last updated on 10/15/08, revealed the interdisciplinary care team identified Resident #62 exhibited behavioral symptoms that may be harmful to self and/or others or that interfered with function or care, as evidenced by ""cognitive deficit Alzheimer's, doesn't understand the need to be here."" The goals associated with this problem statement were no injury to self or others and to reduce the frequency of behavioral symptoms. Interventions included: ""1:1 conservation to calm, reminisce, see act poc (see activity plan of care), offer to call family."" Another problem statement addressed: ""Socially inappropriate - yells out loud for nurses to help her. Yells that she's sick or has to go to the bathroom; anxious / repetitive questions, statements."" The goal associated with this problem statement was: ""Will exhibit socially appropriate behaviors."" Intervention included: ""offer reassurance, encourage rest encourage activities, separate from stressful situations, offer to call son, take for a walk."" Review of the resident's most recent MDS, dated [DATE], revealed Resident #62 had short and long term memory problems and moderately impaired cognitive skills for daily decision making, and she exhibited negative statements, repetitive questions, repetitive verbalizations, unrealistic fears, recurrent statements that something terrible was about to happen, repetitive anxious complaints, [MEDICAL CONDITION], sad / pained / worried facial expressions, crying / tearfulness, and repetitive movements (all of which were not easily altered). Additionally, the assessor identified that the resident exhibited wandering, verbally abusive, physical abusive, and socially inappropriate behaviors and resists care (all of which were not easily altered). Review of the behavior tracking report, from 09/11/08 through 10/10/08, revealed she exhibited behaviors on only four (4) days during the two-month period (09/30/08, 10/06/08, 10/07/08, and 10/10/08). The behaviors being tracked were: negative statements, repetitive questions, repetitive verbal, persistent anger, self deprecation, unrealistic fears, terrible things to happen, repetitive health, unpleasant mood, [MEDICAL CONDITION], sad / pained / worried facial expression, crying, repetitive physical, mood persistence, wandering, wandering altercation, verbal abuse, verbal altercation, physical abuse, physical altercation, socially inappropriate, social altercations, and resists care. Specific examples of these behaviors (such as what constituted ""mood persistence"") were not identified in either the resident's assessments, care plan, or behavior tracking report. The facility failed to develop an individualized care plan to address specifically identified behaviors exhibited by the resident based on a comprehensive assessment of factors causing or contributing to these behaviors, and failed to develop individualized, realistic interventions in recognition of this resident's limited cognitive ability and identified triggers. f) Resident # 81 Medical record review (on 01/06/09) of the physical restraint / enabler plan of care, dated 09/24/08, revealed the following problem statement: ""Refer to the physical restraint / enabler assessment."" The associated goal was: ""Will be free of negative effects with the use of the enabler"". The plan did not identify the reason for use of the enabler and did not establish a goal based on the assessment and the use of the enabler. .",2014-02-01
11481,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,309,D,,,UFEY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, the facility failed to provide care in accordance with each resident's plan of care for three (3) of twenty (20) sampled residents. Resident #97 indicated she was in pain, and this expressed pain was not further assessed or treated. Resident #10 was receiving intravenous (IV) fluids on an ""as needed"" (PRN) basis for her poor fluid intake, and her fluid intake and output were not being accurately monitored; this same resident was observed to have severely contracted hands, and she did not have rolled wash cloths or any type of devices in her hands for positioning to prevent further contractures. The facility also failed to staff applied double geri-gloves and elevated the heels of Resident #40 as ordered by the physician. Resident identifiers: #97, #10, and #40. Facility census: 113. Findings include: a) Resident #97 Record review found a nursing note recording the resident requested pain medication at 10:50 a.m. on 12/18/08. The nurse noted having instructed the resident that her ""pain medications are scheduled"". There was no evidence that the nurse assessed the pain or offered her one (1) of her prescribed PRN medications for breakthrough pain. Another nursing note, dated 12/30/08 at 1:30 p.m., stated, ""Resident belligerent with staff today about her pain medicine ([MEDICATION NAME]). Resident is on pain medication around the clock, offered Tylenol in between doses, resident refused meds (Tylenol). "" Another note, dated 01/01/09 at 4:35 a.m., stated, ""Resident requested this nurse to give pain pill early, when this nurse refused resident became upset mumbled statements under her breath, and accepted her set schedule resting at this time."" A nursing note, dated 01/01/09 at 1:35 p.m., stated, ""Resident upset pain meds are on a scheduled basis instead of PRN. Attempted redirection but resident became more agitated. Continue to monitor."" There was no evidence of further monitoring in the nursing notes, and this was the last nursing note written as of 01/06/09, which was the date of this medical record review. A review of the physician orders [REDACTED]. The resident also had a PRN order for [MEDICATION NAME]. There was no evidence in Resident #97 that staff offered the [MEDICATION NAME] for breakthrough pain between the scheduled doses of [MEDICATION NAME]. During an interview with Resident #97 on 01/06/09 at 10:00 a.m., she identified that her scheduled pain medication was not always effective. She stated that, sometimes, the pain in her back and shoulder was severe. A review of the resident's care plan, dated 11/25/08, revealed this resident had persistent (chronic) pain with ""an alteration in comfort related to pain secondary to L (left) shoulder pain."" Pre-printed goals were checked for this problem statement as follows: ""Decrease persistent pain to a tolerated level so resident can function in daily life""; ""Resident will report pain relief within 30 - 60 minutes receiving pain medication or treatment as ordered; and ""Will have not signs and symptoms of unrelieved pain no complaints of pain when questioned, no vocalization related to pain, no non-verbal signs, verbalization of pain, no decline in activity."" Also included were the following functional goals: ""Participate in ADL's""; ""Participate in therapies""; ""Will not experience decline in functioning related to pain""; and ""Non-pharmacological measures will be used as alternatives to medication when appropriate."" The interventions for achieving the goals written above were as follows: ""Administer pain medication as ordered, Tylenol 650 mg po (by mouth), monitor and record effectiveness, side effects of medication PRN (as needed) observe and notify provider for s/s (signs / symptoms) of constipation, administer bowel care per protocol, assess for verbal and non-verbal signs and symptoms of distress or pain unrelieved by ordered treatments / medications, observe during rest and during movement for pain, [MEDICATION NAME] 50 mg po (by mouth) q4h (every four hours) PRN, [MEDICATION NAME] 5/500 ([MEDICATION NAME]) q4h PRN, position changes, encourage mobility, physical activity as tolerated to prevent stiffness / contractures, Physical therapy and Occupational therapy to evaluate and treat as ordered to improve functional states, refer to pain management clinic PRN, discuss progress toward or maintenance goals for medication therapy, review medication regimen with the provider and the pharmacist PRN."" This care plan was not individualized, and the stated interventions were not initiated when the resident expressed that her routine pain medication was not effective. The nurse did not offer her the PRN [MEDICATION NAME] for breakthrough pain, and there was no evidence that, when the resident expressed continued pain between the routine doses of [MEDICATION NAME], the nurse assessed the pain (type, location, severity, etc.) and provided alternate interventions. The director of nursing (DON - Employee #2) was notified, on 01/07/09 at 6:30 p.m., of the episodes of pain which were not thoroughly assessed and treated by the nurse. The DON agreed the nurse did not intervene according to the standards of practice when the resident expressed the need for additional pain medication. b) Resident #10 1. The physician' s orders, dated 01/01/09, contained an entry for: ""0.45% NS (normal saline) infuse at 75cc/hr PRN if not eating / drinking."" Medical record review revealed the resident was not eating, and she was receiving comfort care. The family did not desire a feeding tube, but they did want the IV fluids for hydration. This resident was observed on 01/05/09 at 2:30 p.m. with IV fluids infusing into her right hand. Another observation, at 6:00 p.m. on 01/06/09, found two (2) different nursing assistants attempting to feed this resident. She would not eat, spitting the food out and turning her head. She also was not drinking. The IV fluids were infusing at 75cc/hour at that time. Review of the medical record revealed staff was not accurately recording the amounts of fluid received by the resident on a daily basis. This IV fluid was ordered ""as needed"" and not continuously, and there was no record of accurate intake of these fluids per shift. There was no intake and output (I&O) record in the medical record on 01/01/09 or 01/05/09. It could not be determined, from the medical record, how much fluid intake this resident. Additionally, the resident's fluid output was not recorded on the I&O worksheets. This resident had an indwelling Foley urinary catheter, which would facilitate the measurement of the resident's urinary output. However, the urinary output was not recorded, and there was no evidence that anyone had compared the resident's output to the intake to check for a fluid balance. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to the MAR, there was no documentation to reflect IV fluids were administered on 01/06/09, and there was no intake records found for that day; however, this surveyor observed IV fluids being administered on 01/06/09 at a rate of 75cc/hour. During an interview with the minimum data set assessment (MDS) nurse (Employee #23) at 10:45 a.m. on 01/07/09, on she was asked if fluid I&Os were recorded elsewhere. She was unable to locate any further records of fluid I&O, and she verified there was no evidence the resident's fluid balance was being adequately monitored. 2. Resident #10 also had contractures to both hands. The resident's most current plan, updated on 11/25/08, specified as an intervention: ""Rolled up washcloths in left hand at all times."" The care plan also stated, ""Place resting splint on right hand from 9:00 a.m. to 3:30 p.m.""; staff was to place a rolled up washcloth in her right hand after the splint was removed. On multiple occasions on 01/05/09, 01/06/09, 01/07/09, and 01/08/09, observation found nothing in this resident's hands to prevent further contractures. On two (2) different occasions, the resident was wearing socks over her hands, but there were no devices in place to address the resident's contractures. During an interview with the MDS nurse at 10:45 a.m. on 01/07/09, she stated this resident should have had something for positioning in her hands due to the contractures. c) Resident #40 1. Medical record review, observation, and staff interview (on 01/06/09 and 01/07/09) revealed Resident #40 did not have on the ""double Geri gloves at all times"" as ordered by her physician. Observation of the resident, with the MDS nurse on 01/06/08 at about 11:00 a.m., found the geri gloves were above her wrist and were not the double gloves. 2. The resident also had a physician's orders [REDACTED].@ all times"". Observation of the resident, with the MDS nurse on 01/06/08 at about 11:00 a.m., found both heels were resting directly on the beds. .",2014-02-01
11482,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,371,F,,,UFEY11,"Based on observations and staff interview, the facility failed to assure foods were 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. This practice has the potential to affect all residents who receive nourishment from the dietary department. Facility census: 113. Findings include: a) At 2:30 p.m. on 01/05/09, observations, during the initial tour of the dietary department, revealed two (2) trays of cups and five (5) trays of cereal bowls; the cups and bowls were inverted on a synthetic shelving mat on flat trays prior to air drying. The cups and bowls were observed with trapped moisture, creating a medium for bacterial growth. The assistant dietary manager (Employee #45) was present and confirmed the identified problem. b) Observation with the dietary manager (Employee #42), on the afternoon on 01/07/09, again revealed inverted cups on a flat tray with a shelving mat which prevented the cups from proper air drying. The tray was observed under the area where the residents' food trays were served in the dining room. .",2014-02-01
11483,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,441,E,,,UFEY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on record review, staff interview, resident interview, and review of the infection incidence rate reports, the facility did not maintain an effective infection control program whereby infectious organisms leading to urinary tract infections (UTIs) were identified. Subsequently, the facility had no data by which analyze infection control data for trends and clusters. Organisms were not identified on the infection incidence log, nor were they tracked for infection control purposes. There was no evidence that clusters were identified. This was evident for four (4) of twenty (20) sampled residents. Resident identifiers: #11, #65, #75, and #35. Also, Resident #97 reported improper perineal care that could potentially cause a UTI from fecal contamination. Facility census: 113. Findings include: a) Residents #11 and #85 Resident #11 experienced repeated UTIs colonized with Escherichia coli (E. coli), bacteria found in feces. Record review revealed positive urine cultures for E. coli on the following dates: 05/18/08, 06/21/08, 08/28/08, 10/20/08, 12/07/08. Other organisms cultured included Alpha Streptococcus and [MEDICATION NAME] species on 07/25/08. Resident #11's roommate, Resident #85, also experienced UTIs as evidenced by positive urine cultures of E. coli with colony counts greater than 100,000 for the following dates: 09/23/08 and 11/03/08. Resident #85 also had a UTI identified in the emergency roiagnom on [DATE] (which was treated with Cipro), but the facility was unable to produce that culture report. Review of the facility's most recent quarter's infection incidence rate report (October, November, and December 2008) found Resident #11's E. Coli infections were not recorded for either October or December. With permission, perineal care was observed for Resident #85 on 01/07/09 at 1:45 p.m., after an episode of urinary incontinence. The nursing assistant used a [MEDICATION NAME] Care body wash / shampoo product for cleansing. After the incontinence brief was removed and the resident was cleansed, the nursing assistant used her contaminated gloved hands to pull up the resident's covers and pull back the privacy curtain between the two (2) beds. During interview with the director of nursing (DON - Employee #2) on 01/07/09 at approximately 6:30 p.m., she produced the facility's most recent quarter (October through December 2008) of monthly incidence rates of infections. This form was to contain the names and room numbers of each resident with infection as well as the types of infection (i.e., respiratory, urinary, skin), the onset date, antibiotic prescribed, and the type of precautions utilized. All of the precautions for all of the infections (regardless if UTI, respiratory, or skin) were listed as ""standard"" precautions for those three (3) months. The accompanying infection surveillance worksheets listed the onset of symptoms, whether it was urinary or respiratory, the name of the antibiotic prescribed, and the start / stop dates of the antibiotic. Neither the organisms isolated, nor the antibiotics the organisms were resistant to, nor the date and site of the culture were listed on any of the infection surveillance worksheets, although there were designated places on the form for recording each these items. A breakdown of numbers of residents with infections were recorded during the most recent quarter as follows: - October - twenty-two (22) residents with sixteen (16) infection surveillance worksheets; - November - twenty-four (24) residents with nine (9) infection surveillance worksheets; - December - eighteen (18) residents with seven (7) infection surveillance worksheets. The DON stated she did not track the infectious organisms anywhere and was not aware of any method they used to assess for clusters of organisms (e.g., to determine whether staff may be communicating infectious organisms between residents on the same unit, etc.). b) Resident #65 During record review on 01/06/09, the record revealed Resident #65 had a urinalysis laboratory report showing a UTI, reported on 11/06/08. This urinalysis / urine culture report identified E. coli as the infecting organism. The record contained another urinalysis laboratory report showing a UTI, reported on 10/25/08. This urinalysis / urine culture report identified Citrobacter freundii as the infecting organism. On 01/07/09, review of the infection control report / log for November 2008 did not show this resident's name, the presence of a UTI, or the cultures infectious. Review of the October 2008 infection control report / log, on 01/07/09, revealed this resident's name and ""UTI""; however, the infecting organism was not noted. On 01/07/09 at 6:30 p.m., the DON (who was also the infection control nurse) was made aware of these findings. No additional documentation was provided. c) Resident #75 Record review, on 01/07/09, revealed Resident #75 was seen at the emergency department at a local hospital on [DATE] - 12/19/08. The ""Hospital to Extended Care Facility Transfer Information"" form (dated 12/19/08) recorded a [DIAGNOSES REDACTED]. The facility subsequently obtained the laboratory report and provided copy to the surveyor on 01/08/09. This urine culture laboratory report identified Proteus mirabilis as the infecting organism. On 01/08/09, review of the infection control report / log for December 2008 revealed this resident's name with ""URI"" (upper respiratory infection) listed. The log did not show the resident's UTI or the infecting organism. d) Resident #35 Record review for Resident #35 revealed a urinalysis (UA) done on 12/19/08. The laboratory results indicated this resident had a UTI with E. coli present. This resident's UTI was treated, but there was no evidence the facility had monitored the infection and investigated the reason for this infection. This type of infection is often caused by inadequate perineal care. There was no evidence that the facility placed this resident on the facility's infection tracking form for tracking or trending. e) Resident #97 During an interview on 01/06/09, this resident stated, ""I have urinary tract infections a lot, and I am careful how I wash."" The resident then explained that she does not like the facility staff to give her a bath or wash her, because ""they do not know how to do it right to keep you from getting an infection."" She said, ""When I came in here, one of the nursing assistants gave me a shower and washed me back to front, and I will not let them wash me anymore."" The resident stated she ""reported this to the desk"" and now they let her take a bath herself. --- Part II -- Based on random observations, the facility failed to ensure staff distributed ice water in a manner to prevent the potential development and transmission of disease and infection. This was evident for all the residents on the 300 Hall and 400 Hall who were allowed to have water pitchers at the bedside. Facility census: 113. a) First observation 01/05/09 at 3:00 p.m., and shortly thereafter on the 300 Hall, a nursing assistant was observed during ice pass holding water pitchers directly over the open ice chest while dipping ice into the residents' used water pitchers, a practice which could potentially transmit microorganisms from the exterior surface of the dirty pitcher to the clean ice which was served to the residents on that hall. The nursing assistant was observed filling two (2) pitchers from room [ROOM NUMBER], one (1) pitcher from room [ROOM NUMBER], and two (2) pitchers from room [ROOM NUMBER] in this manner. At 3:15 p.m., the above observations were reported to the nurse (Employee #27), who immediately spoke with the nursing assistant about the matter. On the 400 Hall, three (3) nursing assistants were observed during ice pass dipping ice into residents' used water pitchers directly over the open ice chest below. At 3:20 p.m., 3:21 p.m., and 3:22 p.m., three (3) nursing assistants were each observed filling two (2) pitchers at a time in this manner, and one (1) single pitcher filled at 3:25 p.m. At 3:26 p.m., this practice was relayed to the corporate nurse (Employee #100), as she also observed one (1) of the three (3) nursing assistants dipping ice into two (2) pitchers directly over the ice chest, and she immediately addressed the situation with that nursing assistant. The corporate nurse then relayed information regarding this practice of dispensing ice to the administrator (Employee #1). b) Second ice pass observation During an observation of medication administration on 01/06/09 at 9:10 a.m., a nursing assistant (Employee #58) was observed passing ice to the residents on the 400 hall. Employee #58 was observed to enter room [ROOM NUMBER] and remove two (2) ice pitchers. The nursing assistant held the ice pitchers over the ice chest and filled them with ice. Following the previous day's observations and management interventions, staff continued to pass ice in a manner which could lead to the spread of microorganisms. .",2014-02-01
11484,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,328,E,,,UFEY11,"Based on random observation, staff interview, and policy review, the facility failed to ensure that residents received proper care for the special service of respiratory care as per facility policy. This was evident for four (4) of six (6) residents on the 300 Hall (Residents #2, #21, #26, and #108) and three (3) residents on the 400 Hall (Residents #48, #62, and #105), whose oxygen delivery supplies were not being changed weekly in accordance with facility policy. Facility census: 113. Findings include: a) Residents #2, #21, #26, and #108 During initial tour of the 300 Hall on 01/05/09 at approximately 2:30 p.m., observation found four (4) of the six (6) residents on that hall had oxygen (02) concentrators with oxygen delivery tubing dated 12/20/08. This was true for Residents #2, #21, #26, and #108. Resident #108 also had a nebulizer tubing and mask dated 12/20/08. (A fifth resident was receiving oxygen but refused the surveyor admittance into her room.) These findings were reported to the nurse (Employee #27) at approximately 2:55 p.m. 01/05/09, who reported that oxygen tubing was to be changed weekly. After checking the above referenced residents, she said she would see they were taken care of and would notify the nurse covering the 300 Hall. b) Residents #48, #62, and #105 On the morning of 01/07/09, observation found two (2) residents on the 400 Hall (Residents #48 and #62) with had no dates on their oxygen tubings. Also on 400 Hall, Resident #105 had a nebulizer tubing dated 12/02/08. These findings were reported, and the tubings were shown to the nurse (Employee #35). When asked who typically changed the oxygen tubing, she replied they were changed weekly, and that Employee #16 usually changed them. c) On 01/06/09 at approximately 2:00 p.m., the facility's Oxygen Administration policy was reviewed. In the revised January 2006 Respiratory Practice Manual, under Section 6.2.1. Oxygen Administration, the policy stated: ""Label nasal cannula (also humidifier) with resident name, date, and liter flow."" Review of Section 2.2.1. General Requirements found, under the procedure for the subject of Disposable Equipment Change Schedule subset 1.n.: ""02 (Oxygen) delivery devices - for example Venturi masks, nasal cannulas, oxygen supply tubings - every 5 days and PRN (as needed)."" When asked on 01/06/09 approximately 2:30 p.m., the director of nursing (DON - Employee #2) said the facility's policy was to change nasal cannulas and tubings weekly. On 01/07/09 at approximately 6:30 p.m., the above findings were reported to the DON. .",2014-02-01
11485,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,164,E,,,UFEY11,"Based on observation, resident interview, confidential resident group interview, and staff interview, the facility failed to maintain resident privacy during showers. This was evident for three (3) of twenty (20) sampled residents and one (1) anonymous resident at the confidential resident group meeting. Resident identifiers: #51, #11, and #85. Facility census: 113. Findings include: a) Resident #51 During an interview on 01/06/09 at approximately 3:00 p.m., Resident #51 reported a lack of privacy in the shower room. She stated she was able to see the buttocks and breasts of other female residents, and that she, too, was exposed to another person in the adjoining shower. There was a big curtain separating the doorway from the shower stalls, but she stated you could see around the curtain where it was not fully block the view. b) Resident #11 On 01/07/09 at 9:25 a.m., Resident #11 was observed during a shower with her permission. She was in the left shower stall being bathed by a nursing assistant, while another resident was in the right shower stall being bathed by a different nursing assistant. A divider shower curtain between the two (2) stalls was present but not being used. Rather, the shower curtain was against the wall behind a Hoyer lift. c) Resident #85 On 01/07/09 at 9:25 a.m., Resident #85 was observed during a shower with permission. She was in the right shower stall being bathed by a nursing assistant, while another resident was in the left shower stall being bathed by a different nursing assistant. A divider shower curtain between the two (2) stalls was present but not being used. Rather, the shower curtain was against the wall behind a Hoyer lift. d) Confidential resident group meeting interview On 01/06/09 at 10:30 a.m., a resident who attended the confidential group meeting reported the shower was not private. She also reported she was not always fully dressed properly when brought out of the shower. When asked for clarification in a separate interview on 01/07/09 at 2:00 p.m. regarding how the shower experience lacked privacy, she said she can see the breasts of residents in the adjoining shower while she is being showered. When asked about the blocks that extended part of the way up the shower stalls on each side facing the other stall, she replied she could see the residents' breasts over the blocks, as they were not high enough to block the view. When asked about the shower curtain between the stalls, she replied she had not ever noticed if there was a shower curtain between the stalls. She clarified she also saw the ""bottoms"" of other residents when they were brought out of the shower stall naked. When asked if there was a curtain between the showers and the main door, she replied in the affirmative but stated, for example, when she was brought in for a shower and was waiting her turn to get in, she could see the bodies of other residents around the curtains, as the curtains were not pulled fully closed and/or gapped open. e) The above findings were reported to the director of nursing (DON - Employee #2) at approximately 6:30 p.m. on 01/07/09. She stated she was not aware of these findings in the facility. .",2014-02-01
11486,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,221,E,,,UFEY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, a review of the incident / accident reports, and staff interview, the facility failed to assure that devices, applied and/or attached to a resident to restrict voluntary movement and/or normal access to one's body, were ordered by a physician to treat a medical symptom after the completion of a comprehensive assessment, to include the development and implementation of plans to systematically and gradually reduce the use of these physical restraints. Staff applied socks to Resident #10's hands, which restricted movement, without a physicians' order. Documentation in the medical records of Residents #36, #5, #28, and #85 inconsistently addressed the purpose of lap buddies applied to prevent rising and subsequent falls; throughout their charts, staff referred to these devices as ""enablers"" instead of physical restraints. Resident #36 consistently resisted the use of her lap buddy, injuring herself when her device was being applied; a plan to address this, as well as a plan for the systematic / gradual reduction of the use of this device, was not initiated. Devices were not adequately addressed for five (5) of twenty (20) sampled residents. Resident identifiers: #10, #36, #35, #28, and #85. Facility census: 113. Findings include: a) Resident #10 During an observation on 01/05/09 at 2:30 p.m., Resident #10 was laying in the bed with a sock applied to her right hand. This sock covered the resident's entire hand and was pulled up to the resident's elbow. Another observation, on 01/06/09 at 10:00 a.m., found socks present on both of the resident's hands, pulled up to her elbows. Review of the resident's medical record, including the monthly recapitulation of physician's orders (dated 01/01/09 through 01/31/09) revealed no active physician's order for any type of physical restraint, including the application of socks on this resident's hands. Review of Resident #10's current care plan, dated 11/25/08, found a plan directing staff to apply ""socks to hands at all times"". The medical symptom for the use of this physical restraint was ""prevent scratching face, removal of O2 (oxygen)"". This care plan then said, ""D/C (discontinue) 12/19/2008."" During an interview with the minimum data set assessment (MDS) nurse (Employee #23) on 01/07/08 at 10:45 a.m., the MDS nurse verified that the intervention to put socks on Resident #10's hands was discontinued on 12/19/08, and restraints should not have been in use on the days this surveyor observed the socks on this resident's hands on 01/05/09 and 01/06/09. b) Resident #36 Review of Resident #36's medical record found a physician's order, dated 12/05/08, stating, ""Resident may have standard size lap buddy to be used to protect resident from injury to herself or others as a therapeutic enabler to maintain the resident's highest physical & mental well being. Will re-evaluate prn (as needed), not to exceed 90 days. Will monitor use of this enabler @ least q (every) 30 minutes & release, assess & provide needs q2hr / prn (every two hours as needed). Resident may be enabler free during meal time while supervised. Use of this enabler is secondary to unsteady gait secondary to dementia."" Further review of the medical record revealed that, on 12/05/08, a ""Physical Restraint / Enabler Assessment"" was completed. Documentation on this assessment stated the conditions and circumstances necessitating the use of the restraint were ""danger of harming self or others"", as well as ""to improve self functioning"" through promoting ""proper positioning"". Instructions on the section titled ""Restraining Device"" stated ""complete if device is a restraint to be used to enhance functioning""; this section was left blank, even though the section above stated the device was being used ""to improve self function"". The next section on the assessment was titled ""Enabler Device"", which was to be completed if the device were an enabler to enhance functionality. The assessor recorded ""poor safety awareness with frequent falls"" as the medical symptom to be treated by the use of the device. The assessor also recorded that the device was to be used when the resident was in the wheelchair. Another form in the medical record titled ""Physical Restraint / Enabler Information"" was reviewed. There was a separate form for various devices used for this resident. These forms described if the device was a physical restraint or an enabler and the potential benefits and risks. (A separate form was completed for the perimeter mattress, the mobility alarm to the bed, the mobility alarm to the wheelchair, the low bed, and the lap buddy.) The form completed for the lap buddy identified was the device as an enabler of which this resident was cognitively aware. Among the benefits for using this device, the assessor recorded reduce risk of falls and maintenance of proper body positioning. The form contained a section titled ""Potential risks of a physical restraint / enabler use may include:""; this section was left blank. Further review of the nursing notes and incident / accident reports revealed this resident did not want the lap buddy attached to her chair, and it caused increased agitation. An incident / accident report, dated 12/05/08 at 7:00 a.m., stated, ""Resident continually tries to get out of chair to bed or from bed to chair. Resident placed in chair, belt alarm on and checked, resident taken to area beside nurses station. Lap Buddy put on and seat belt alarm removed."" An incident / accident report, dated 12/06/08 at 7:00 a.m., stated, ""Res (resident) was pushing at lap buddy while CNA (certified nursing assistant) was trying to put it on her wheelchair and residents wrist band slid and cut her arm."" Further documentation on this report recorded the resident ""stated that she was mad over lap buddy and was trying to keep the CNA from putting it on the WC (wheelchair)"". Another incident / accident report, dated 12/11/08 at 11:30 a.m., stated, ""Res (resident) did not want lap buddy put back on after going to the restroom. She pushed on lap buddy, fighting against the CNA and she got a skin tear on R (right) forearm."" Documentation on this incident / accident report indicated the resident was not compliant with the use of the prescribed assistive device and she tried to remove the lap buddy. An incident / accident report, dated 12/21/08 at 10:00 a.m., stated Resident #36 ""reopened a ST (skin tear) to the L (left) arm. Resident was fighting against CNA who was putting lap buddy on WC. She was flailing her arms around and hit arm on wheelchair."" A nursing note, dated 12/21/08 at 4:30 p.m., recorded, ""Resident continues to kick and hit during the application of lap buddy. Will monitor use of new lap buddy."" A nursing note, dated 12/25/08 at 1:00 p.m., recorded, ""Resident loud and verbal this a.m. (morning) Has made several attempts at removing lap buddy from chair, becomes physically aggressive with staff during care. Continue to monitor."" A nursing note, dated 01/03/08 at 6:30 p.m., recorded, ""Res observed throwing water pitcher full of water onto floor of room. She had also pushed over the bedside table. Resident stated that she wanted her lap buddy removed. Will continue to monitor for adverse behavior."" An interdisciplinary progress note, dated 12/15/08, recorded a new medication was being used and stated, ""She is also not always compliant with wearing double geri-gloves. She will take the off and not let the staff place them."" There was nothing mentioned about the noncompliance with the lap buddy or the fact that this resident was resistant to its use and was injuring herself with this device, which was ordered for safety to prevent injury. The resident's physical restraint / enabler care plan, dated 12/05/08, did not contain a problem, goal, or interventions with respect to the use of the lap buddy to promote increased functioning; the care plan simply said, in the first section, ""Refer to the physical restraint / enabler assessment""; the associated goal was: ""Will be free of negative effects with the use of an enabler."" The interventions listed did not assist in achievement of the stated goal. The interventions were: apply the enabler (lap buddy) when in the wheelchair for poor safety awareness with frequent falls; review the enabler information sheet every ninety (90) days; refer to the Mood and Behavior Symptom Assessment plan of care (which was reviewed and did not refer to the lap buddy in any way or resisting its use); refer to the falls assessment prevention and management plan of care (which did include the lap buddy use); refer to the skin integrity assessment (which did not contain information about the lap buddy) prevention and management plan of care; maintain resident bowel and bladder routine; and educate resident / family about physical restraints / enabler using the physical restraint / enabler information form (which was not complete). The care plan did not identify how the lap buddy was being used to increase the resident's level of functioning, nor did it address the fact that the resident became agitated / resisted using this device and sustained injuries when the device was applied. During a dinner observation at 6:00 p.m. on 01/06/09 and a lunch observation at 12:30 p.m. on 01/07/09, this resident was observed sitting in her room eating independently with the lap buddy still attached to her wheelchair. During an interview with the director of nursing (DON - Employee #2) on 01/07/09 at 6:30 p.m., she stated this device was not a physical restraint; it was an enabler. When questioned about the difference between a physical restraint and an enabler, she indicated that, if a resident could not get up own his/her own, it was not a restraint. She was made aware of the inconsistent documentation and the inadequate assessment of this device for Resident #36. c) Resident #35 Record review revealed the following physician's order dated 12/19/08: ""Lap buddy may be used to protect resident to maintain residents highest physical / mental well being. Will reevaluate prn (as needed) not to exceed 90 days. Will monitor use of this restraint at least 30 minutes and release q 2 hours prn to assess and provide needs as needed. May be restraint free during meal time while supervised. Use secondary to dementia."" Further record review revealed a form titled ""Physical Restraint / Enabler Information"", dated 12/19/08, on which was written ""Lap Buddy"". Documentation on the form indicated the lap buddy was an enabler and the resident could remove it at will. The record contained another form titled ""Physical Restraint / Enabler Assessment. Documentation on this assessment form stated that the conditions for restraint consideration for this resident included ""danger of harming self or others"". Documentation at the bottom of the form indicated the device was an enabler to enhance functionality. According to this information, the enabler device was being used to treat the following medical symptom: ""Unable to ambulate independently secondary to [MEDICAL CONDITION]"". Review of the resident's current care plan, dated 12/05/08, found the statement: ""Refer to the physical restraint / enabler assessment."" The goal associated with this statement was: ""Will be free of negative effects with the use of an enabler."" The interventions were not pertinent to assist with the achievement of this goal. The interventions simply stated: ""Apply enabler, lap buddy, to wheelchair. Medical symptom: poor safety awareness secondary to dementia and [MEDICAL CONDITION]. Review the physical restraint / enabler sheet every 90 days."" The care plan did not identify how the lap buddy was being used to increase the resident's level of functioning. The DON, when interviewed about the use of this lap buddy, verified that the use / purpose of this device was inconsistently documented, and she acknowledged it was ordered by the physician as a physical restraint but was treated by the facility as an enabler. d) Resident #28 Medical record review, conducted on 01/06/09 at 1:32 p.m., revealed Resident #28 had physician's orders for a pommel cushion and a lap buddy. Further review revealed both devices were identified as ""enablers"" to protect her from injury due to decreased safety awareness. Review of the facility document titled ""Physical Restraint / Enabler Information"" found the following difference between a physical restraint and an enabler: - ""A physical restraint is any manual or physical or mechanical device, material or equipment attached or adjacent to the resident body that cannot be easily removed by the resident and restricts freedom of movement or normal access to one's own body."" - ""An enabler is a device, material or a piece of equipment attached or adjacent to the residents' body that the resident can easily remove and is cognitively aware of."" The Centers for Medicare & Medicaid Services (CMS) state, ""Physical Restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body."" On 01/06/09 at 5:30 p.m., the licensed practical nurse (LPN - Employee #36) identified that Resident #28 was not able to remove her lap buddy. Review of the resident's quarterly minimum data set assessment (MDS), dated [DATE], identified the resident's cognitive skills for daily decision making were moderately impaired. The use of the lap buddy with pommel cushion with Resident #28, therefore, did not meet the facility's own definition of an ""enabler"". Review of the facility policy titled ""5.2.1 Physical Restraint / Enabler Program"" revision date April 2006 identifies on page, in section 3-C: ""Select appropriate physical restraint alternative / enabler based on assessment. - Complete Restraining Device Section, if the device is a restraint used to enhance functionality. - Complete Enabler Device Section, if the device is an enabler used to enhance functionality."" Review of the document titled ""Physical Restraint / Enabler Assessment"" for the lap buddy (initially completed on 11/28/07 updated on 02/03/08, 05/14/08, and 11/19/08) found the assessor never identified the lap buddy as a physical restraint. Review of the resident's current care plan, dated 11/26/08, found staff identified the lap buddy as an enabler, although the device met the facility's definition of a physical restraint (not an enabler). The care plan did not contain a systematic and gradual plan towards reducing the use of the restraint (e.g., gradually increasing the time for ambulation and muscle strengthening activities), nor did the care plan identify what care and services would be provided during the periods of time when the restraint would be released or what meaningful activities would be provided. e) Resident #85 Record review revealed Resident #85 used a lap buddy daily, but there was no systematic plan for restraint reduction, release, and meaningful activities to be provided. There was also a discrepancy within the facility's documentation as to whether her lap buddy was a physical restraint or enabler. Documentation on the physical restraint information sheet, dated 4/15/08, noted the application of a lap buddy to her wheelchair and defined a physical restraint as a device that ""cannot be easily removed by the resident and restricts freedom of movement or normal access to one's own body"". The assessor consistently documented in Section P4 of the resident's MDS assessments, dated 06/26/08, 09/25/08, and 12/2508, that a ""trunk restraint"" was in use. During an interview on 01/08/09 at 11:15 a.m., Employee #18 said the MDS assessments were coded incorrectly, and the lap buddy should have been coded as a chair preventing rising, and agreed they should have one (1) care plan per device. Review of Resident #85's current care plan found the use of a physical restraint was initially developed on 04/15/08. The care plan did not specify interventions of a systematic plan for restraint reduction nor for planned releases of the lap buddy. The care plan also did not specify meaningful activities, rather it stated to ""See Activity Pursuit POC"" (plan of care). Review of the activity pursuit plan of care found interventions of large music groups, socials, parties, and visits with family, but there were no plans to offer diversional activities as a part of a restraint reduction plan to keep the resident engaged, so that a physical restraint may not be necessary. Interview with the activities director (Employee #11), on 01/08/09 at 2:00 p.m., revealed her belief that Resident #85 had declined a lot the past few months and no longer took part in many activities; she estimated the resident's attention span to be ten (10) minutes at the most. She said she did provide for Resident #85 one-on-one activities two (2) or three (3) times per week. She cited the resident's illness in September as the beginning of her decline and produced an activity record for August that evidenced much more participation in activities. Random observation on 01/07/09, between 11:15 a.m. and 11:30 a.m., found her up in the wheelchair with the lap buddy in place. During this time, she entered four (4) residents' rooms. Housekeeping staff brought her out once, a nursing assistant brought her out once, and she left on her own accord twice. Another random observation on 01/07/09, between 11:33 a.m. and 11:41 a.m., revealed she was up in the wheelchair with the lap buddy in place. Her daughter came in for a visit to feed her and to walk around the building with her, and she continued to have the lap buddy in place throughout the family visit until the daughter left at 1:30 p.m. She was returned to bed at 1:45 p.m. after being in the wheelchair with the lap buddy for at least two and one-half (2-1/2) hours. On 01/07/09 at 6:15 p.m., the DON stated a ""restraint is anything that restricts you from standing up"", citing if a resident could not stand up voluntarily anyway, then the device was an enabler (not a physical restraint). She stated that, if a resident were leaning or scooting out of a chair, then the lap buddy would also be an enabler; she replied in the affirmative when asked if a tied restraint would also be an enabler in that same situation. She said she believed an enabler was coded as a trunk restraint on the MDS. .",2014-02-01
11487,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,285,D,,,UFEY11,"Based on record review and staff interview, the facility failed to assure that a Level II evaluation was completed, when indicated, prior to the admission of one (1) of twenty (20) sampled residents. Resident identifier: #108. Facility census: 113. Findings include: a) Resident #108 Record review, on 01/07/09, revealed Resident #108 was admitted to the facility in 2008. The Pre-Admission Screening and Resident Review (PASRR) Determination, dated eleven (11) days prior to the current admission, stated that a Level II evaluation was required for this individual. However, the Level II evaluation itself was not completed prior to this admission to this facility. These findings were reported to Employee #8 on the morning of 01/08/09. She, in turn, referred the matter to the admissions / social worker to see if more information was on record in the social worker's office. On 01/08/09 at approximately 11:55 a.m., Employee #8 produced a Level II assessment signed by a supervised psychologist that was dated six (6) days after Resident #108's current admission. Employee #8 stated they thought the PASRR had been completed by the transferring facility. The finding of the delinquent pre-admission Level II evaluation was reported to the director of nursing at approximately 6:30 p.m. on 01/07/09. .",2014-02-01
11488,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,329,D,,,UFEY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility did not ensure the medication regimen of one (1) of twenty (20) sampled residents was free from unnecessary drugs without adequate indications for use. Resident #62 was under the care of a psychiatrist for her mood / behavior, having been evaluated on 05/09/08; in addition to medication changes, the psychiatrist recommended a follow-up appointment within nine (9) weeks or as necessary. Additional psychoactive medications ([MEDICATION NAME] and [MEDICATION NAME] ER) were added to the resident's medication regimen without first assessing for [MEDICATION NAME] / extrinsic factors that may have caused or contributed to changes in the resident's behavior and/or without contacting the psychiatrist. Resident identifiers: #62. Facility census: 113. Findings include: a) Resident #62 1. Medical record review, on 01/06/09 at 4:15 p.m., revealed Resident #62 received several psychoactive medications for mood / behavior, including [MEDICATION NAME], and [MEDICATION NAME]. Further review revealed a psychiatric evaluation was completed on 05/09/08, after which the psychiatrist recommended increasing her [MEDICATION NAME] and instructed the facility to watch her for serotoni[DIAGNOSES REDACTED], since she was already receiving [MEDICATION NAME] and [MEDICATION NAME]. The psychiatrist also recommended a follow-up appointment in nine (9) weeks, or sooner if needed. Subsequent to the psychiatric consult, the resident's attending physician increased the [MEDICATION NAME] to 0.5 BID on 05/10/08 and decreased her [MEDICATION NAME] to 5 mg BID on 05/15/08. 2. At the beginning of June, Resident #62 began to exhibit increased anxiety, and in July, she had a panic attack. The facility did not contact the psychiatrist regarding these events. 3. On 09/30/08, she exhibited increased behaviors and was given [MEDICATION NAME] 1 mg intramuscularly (IM). Nursing progress notes did not contain any documentation to reflect an assessment for [MEDICATION NAME] or extrinsic factors that may have caused or contributed to the increase in behaviors. On 10/01/08, she again exhibited increased behaviors, and she was given [MEDICATION NAME] 1 mg IM. The facility did not contact the psychiatrist regarding these events. A urinalysis later revealed Resident #62 had a urinary tract infection [MEDICAL CONDITION]. The facility failed to rule out [MEDICATION NAME] or extrinsic causes of the increased behaviors prior medicating her with [MEDICATION NAME] IM. 4. On 11/12/08, the attending physician added [MEDICATION NAME] ER to the resident's medication regimen. There was no evidence to reflect the facility contacted the psychiatrist regarding changes in the resident's behaviors / condition for which the attending physician added the [MEDICATION NAME] ER. 5. On 01/07/09 at 4:15 p.m., the director of nursing (DON - Employee #2) was questioned if psychiatric services was consulted upon increase in behaviors. On 01/08/09, the DON was unable to provide any information to show that the facility had contacted the resident's psychiatrist after any of the episodes which resulted in changes in her psychoactive medications. .",2014-02-01
11489,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,520,E,,,UFEY11,"Based on medical record review, review of the facility's infection control tracking log, and staff interview, the facility failed to maintain a quality assessment and assurance (QAA) committee that identifies quality deficiencies (of which it should have been aware) and develops / implements plans of action to correct these deficiencies. The facility had a high number of residents with urinary tract infections (UTIs). The QAA committee failed to identify deficits in the infection control program (with respect to tracking infectious organisms, identifying trends through analysis of the facility's infection control data, and investigating the UTIs to identify any underlying causal or contributing factors) and failed develop / implement measures to address these deficits. Facility census: 113. Findings include: a) Record review, during the facility's annual certification resurvey conducted from 01/05/09 through 01/08/09, revealed multiple residents with UTIs, several of whom had the same infectious organism and resided in the same location (same room and/or hall within the facility). On the afternoon of 01/06/09, the director of nursing (DON - Employee #2) was identified as the individual designated as responsible for infection control tracking. At this time, a copy of the November and December 2008 infection control tracking logs was requested and received. A review of the infection control tracking logs revealed the DON / infection control nurse failed to log the organisms identified through cultures as being responsible for each infection. In an interview with the DON and administrator (Employee #1) on 01/07/09 at 4:30 p.m., the DON acknowledged that she did not record infectious organisms on the tracking logs. During interview with the director of nursing (DON) on 01/07/09 at approximately 6:30 p.m., she produced the facility's most recent quarter (October through December 2008) of monthly incidence rates of infections. This form was to contain the names and room numbers of each resident with infection as well as the types of infection (i.e., respiratory, urinary, skin), the onset date, antibiotic prescribed, and the type of precautions utilized. All of the precautions for all of the infections (regardless if UTI, respiratory, or skin) were listed as ""standard"" precautions for those three (3) months. The accompanying infection surveillance worksheets listed the onset of symptoms, whether it was urinary or respiratory, the name of the antibiotic prescribed, and the start / stop dates of the antibiotic. Neither the organisms isolated, nor the antibiotics the organisms were resistant to, nor the date and site of the culture were listed on any of the infection surveillance worksheets, although there were designated places on the form for recording each these items. A breakdown of numbers of residents with infections were recorded during the most recent quarter as follows: - October - twenty-two (22) residents with sixteen (16) infection surveillance worksheets; - November - twenty-four (24) residents with nine (9) infection surveillance worksheets; - December - eighteen (18) residents with seven (7) infection surveillance worksheets. The DON stated she did not track the infectious organisms anywhere and was not aware of any method they used to assess for clusters of organisms (e.g., to determine whether staff may be communicating infectious organisms between residents on the same unit, etc.). There was no evidence that the facility's QAA committee had been monitoring the effectiveness of the facility's infection control program. (See also citation at F441.) Quality deficiencies would have been evident had the QAA committee members reviewed the facility's infection incidence rate reports and/or infection surveillance worksheets, which were incomplete. .",2014-02-01
11490,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,225,D,,,UFEY11,"Based on a review of the facility's complaint files, observation, and staff interview, the facility failed to immediately report and/or thoroughly investigate injuries of unknown origin and allegations of abuse to the appropriate State agencies. For Resident #96, an allegation of abuse was reported to the facility and investigated, but the facility did not report the allegation to State agencies. Resident #75 had bruising of unknown origin to her leg and lower back area, and this was not reported or investigated. This was true for one (1) of six (6) randomly reviewed complaints (#96), and one (1) of twenty (20) sampled residents (#75). Facility census: 113. Findings include: a) Resident #96 Review of the facility's complaint files found a concern report, dated 12/02/08, documenting that this resident's daughter called and said her mother said her legs were hurting and, when the resident was given a shower, ""the aids (sic) hurt her legs and were rough with her"". The facility conducted an internal investigation and took statements from the aides, but the allegation of abuse / mistreatment was not immediately reported to State agencies as required, nor were the results of the facility's investigation forwarded to the State within five (5) working days of the incident. During an interview with the director of nursing (DON - Employee #2) on 01/07/09 at 6:30 p.m., she verified this incident was investigated but was not reported as abuse, stating it was already resolved by the time the concern was filed by the family. b) Resident #75 A record entry on a Physician Notification form, dated 01/07/09, noted bruises of unknown origin to the right inner thigh (measuring 18 cm x 0.25 cm) and the left inner thigh (measuring 1 cm x 8 cm) and a buttock abrasion (measuring 2.3 cm x 2 cm). The entry noted the physician was notified of these injuries at 8:40 a.m. on 01/07/09. During a review of the facility's incident / accident reports for that day, there was no evidence that an accident / incident report had been completed. There was also no evidence that this bruising of unknown origin was investigated or reported to the appropriate state agency. During an interview at 12 noon on 01/08/09, the DON stated she did not report the injuries. During an interview at 12:10 p.m. on 01/08/09, the administrator stated she would check into these injuries. She subsequently confirmed there was no accident / incident report and the injuries were not been reported to the State agencies. There was no formal investigation initiated to find the cause of the injuries. A ""late entry"" accident / incident report was shown to the surveyor at 1:30 p.m. on 01/08/09. .",2014-02-01
11491,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,313,D,,,UFEY11,"Based on observation, record review, and resident interview, the facility failed to assist residents with the use of assistive devices needed to maintain hearing or vision. Residents were observed without their assistive devices in place, which could affect their abilities to interact with their environment. This occurred for two (2) of twenty (20) sampled residents. Resident identifiers: #65 and #36. Facility census: 113. Findings include: a) Resident #65 On 01/07/09 at 10:00 a.m., Resident #65, when observed in physical therapy (PT), was not wearing eyeglasses. During resident interview, Resident #65 stated she needed her glasses both to read and to ""see all the time"". Staff members were present at the time this surveyor was questioning the resident, and one (1) staff member went to get the resident's glasses and returned to PT. She then placed the eyeglasses on the resident's face. b) Resident #36 During initial tour of the facility on 01/05/09 at 2:30 p.m., this surveyor spoke to Resident #36. The resident did not answer questions and looked at the surveyor with a puzzled look. The surveyor introduced herself and asked what her name was. She did not answer or give any sign that she understood what was being asked of her. During another visit on the morning of 01/06/09, Resident #36 was observed sitting up in her wheelchair; she had just finished eating her breakfast. This surveyor spoke to the resident, and again she looked puzzled as if she did not understand what was being said. The surveyor the leaned down and spoke louder and directly into the resident's left ear, asking how her breakfast was. The resident immediately started discussing her breakfast and responded appropriately to each question subsequently asked of her when it was spoken directly into her ear. The resident stated, ""I don't hear well."" After this, all communication was understood by this resident. In a nursing note entry, dated 01/07/09 at 10:00 p.m., the nurse recorded, ""Resident noted to refuse to interact with staff members for brief period, ignored this nurse when asked to take medications. VS (vital signs) were WNL (within normal limits)."" The nurse then indicated that, when the nursing assistant addressed the resident, the resident responded cooperatively. During medical record review, the resident's hearing was reviewed. The admission assessment, dated 04/08/08, indicated the resident had hearing aids. The minimum data set (MDS) assessment indicated the resident did not have problems understanding others when a a hearing device was used. The care plan identified the resident was hard of hearing and contained an intervention - ""hearing aid clean"" . The care plan did not direct the caregiver to be sure the resident wore the hearing aids when she was up and/or to be sure that the hearing aids were working properly. A nursing assistant (Employee #63) was observed providing care for this resident at 12:30 p.m. on 01/08/09. She was asked if she had provided care to this resident in the past, and she said she had been here a while and had worked with this resident many times. When asked if she was aware the resident had hearing aids, she stated she was not aware of this and she had not seen them. At that time, Resident #36's roommate, from behind the privacy curtain, said, ""She has them in her drawer at her bedside."" The nursing assistant looked in the drawer and found two (2) hearing aids in a small case. The nursing assistant tried them and said that they must need batteries, because they were not working. The facility did not assure this resident's assistive hearing devices were clean, working properly, and placed in her ears so that she could communicate with and understand others. .",2014-02-01
11492,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2010-10-07,517,F,,,50Z111,". NFPA 101 Life Safety Code 2000 Edition Chapter 19 Existing Health Care Occupancies 19.7.1 Evacuation and Relocation Plan and Fire Drills. 19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1) Use of alarms (2) Transmission of alarm to fire department (3) Response to alarms (4) Isolation of fire (5) Evacuation of immediate area (6) Evacuation of smoke compartment (7) Preparation of floors and building for evacuation (8) Extinguishment of fire - NFPA 99 Standard for Health Care Facilities 1999 Edition Chapter 11 Health Care Emergency Preparedness 11-2 Purpose. The purpose of this chapter is to provide those with the responsibility for disaster management planning in health care facilities with a framework to assess, mitigate, prepare for, respond to, and recover from disasters. This chapter is intended to aid in meeting requirements for having an emergency preparedness management plan. 11-4.2 Senior Management. It shall be the responsibility of the senior management to provide its staff with plans necessary to respond to a disaster or an emergency. Senior management shall appoint an emergency preparedness committee, as appropriate, with the authority for writing, implementing, exercising, and evaluating the emergency preparedness plan. This standard is not met as evidenced by: Based on review of the facility's disaster and emergency evacuation plan, the facility did not have a detailed written disaster and emergency evacuation plan. Facility census: 81. Findings include: a) On 10/06/10 at approximately 12:45 p.m., a review of the facility's disaster and emergency evacuation plan was conducted. At this time, the disaster and emergency evacuation plan did not contain a detailed plan for the safety of residents and staff in the event of a disaster and emergency evacuation. The facility's evacuation procedures addressed vertical and horizontal evacuation within the building and not the evacuation from the building, in the event a complete evacuation would be required.",2014-02-01
11493,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2010-10-07,456,F,,,50Z111,". Based on observation, staff interview, and measurements of ambient room air temperatures, the facility failed to maintain heating boilers in a safe operating condition. Facility census: 81. Findings include: a) Interview with the facility's administrator and the maintenance director, on 10/04/10 at approximately 1:40 p.m., revealed the facility's heating boiler system was in need of repair. The boilers intended to heat the resident rooms and common areas had been inspected by a boiler inspector and were ""red tagged"" as not operational (prohibiting the use of the boiler system until defects in the system were corrected) during inspections dated 08/06/10 and 08/09/10. At the time of this interview, the administrator and maintenance director related a plan for the installation of a temporarily heating boiler for use during the winter until permanent repair / replacement of the existing heating boiler system could be implemented. This process would take approximately three (3) weeks, during which the facility had to solicit competitive bids for a temporary heating boiler before a contract could be awarded to a outside vendor for installation. - b) Ambient air temperatures of resident rooms were taken by the life-safety code (LSC) surveyor, accompanied by a licensed practical nurse (LPN - Employee #158), between the hours of 5:30 a.m. to 6:35 a.m. on 10/05/10. Fifty-eight (58) of sixty-five (65) occupied resident rooms were found to be below 70 degrees F, and nineteen (19) of sixty-five (65) occupied resident room were found to be below 65 degrees F. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/04/10, measured at 3:35 a.m., was 43 degrees F. The outside ambient air temperature, during the time of testing resident rooms on the morning of 10/05/10, was found to be 49 degrees F. - c) Resident room ambient air temperatures were taken again between the hours of 8:30 a.m. to 9:15 a.m. on 10/06/10. At this time, forty-four (44) of forty-eight (48) occupied resident rooms tested were found below 70 degrees F, and twenty (20) of forty-eight (48) occupied resident rooms were below 65 degrees F. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/05/10, measured at 11:59 p.m., was 41 degrees F. The outside ambient air temperature, during the time of testing resident rooms on the morning of 10/06/10, was 46 degrees F. - d) A review of the National Weather Service's extended seven (7) day forecast for the Beckley area, for 10/06/10 through 10/12/10, revealed low temperatures ranging from 40 to 49 degrees F. With the boilers not operational, the facility could not maintain safe and comfortable environment for residents to prevent the risk of hypothermia. (See also citations at F224 and F257.) .",2014-02-01
11494,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2010-10-07,257,F,,,50Z111,". Based on observation, staff interviews, measuring of ambient air temperatures, and information from the National Weather Service, the facility failed to maintain comfortable and safe temperatures (between 71 and 81 degrees Fahrenheit (F)) throughout the building to minimize the risk of hypothermia. Ambient air temperatures in occupied resident rooms, measured in the presence of facility staff, were found to be below 65 degrees F. This deficient practice presented the potential for more than minimal harm to all residents in the facility and constitutes a finding of substandard quality of care. Facility census: 81. Findings include: a) Interview with the facility's administrator and the maintenance director, on 10/04/10 at approximately 1:40 p.m., revealed the facility's heating boiler system was in need of repair. The boilers intended to heat the resident rooms and common areas had been inspected by a boiler inspector and were ""red tagged"" as not operational (prohibiting the use of the boiler system until defects in the system were corrected) during inspections dated 08/06/10 and 08/09/10. - b) Ambient air temperatures of resident rooms were taken by the life-safety code (LSC) surveyor, accompanied by a licensed practical nurse (LPN - Employee #158), between the hours of 5:30 a.m. to 6:35 a.m. on 10/05/10. Fifty-eight (58) of sixty-five (65) occupied resident rooms were found to be below 70 degrees F, and nineteen (19) of sixty-five (65) occupied resident room were found to be below 65 degrees F. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/04/10, measured at 3:35 a.m., was 43 degrees F. The outside ambient air temperature, during the time of testing resident rooms on the morning of 10/05/10, was found to be 49 degrees F. Ambient temperatures of occupied resident rooms, measured on 10/05/10 between 5:30 a.m. and 6:35 a.m., were as follows: B333 - 71 degrees F; B331 - 65 degrees F; B329 - 62 degrees F; B327 - 62 degrees F; B325 - 66 degrees F; B323 - 67 degrees F; B321 - 72 degrees F; B317 - 70 degrees F; B315 - 68 degrees F; B313 - 69 degrees F; B311 - 62 degrees F; B309 - 59 degrees F; B310 - 60 degrees F; B324 - 67 degrees F; B326 - 66 degrees F; B328 - 64 degrees F; B330 - 63 degrees F; B332 - 63 degrees F; C315 - 63 degrees F; C314 - 67 degrees F; C313 - 69 degrees F; C312 - 73 degrees F; C311 - 65 degrees F, C307 - 71 degrees F; C306 - 64 degrees F; C305 - 66 degrees F; C304 - 70 degrees F, C303 - 68 degrees F; C301 - 66 degrees F; C300 - 64 degrees F; C302 - 67 degrees F, C308 - 66 degrees F; C309 - 67 degrees F; C310 - 68 degrees F; C316 - 61 degrees F, C317 - 68 degrees F; B129 - 63 degrees F; B127 - 62 degrees F; B125 - 68 degrees F, B123 - 67 degrees F; B121 - 66 degrees F; B119 - 68 degrees F; B117 - 72 degrees F, B113 - 73 degrees F; B122 - 64 degrees F; B124 - 63 degrees F; B126 - 61 degrees F, C115 - 65 degrees F; C114 - 61 degrees F; C113 - 65 degrees F; C112 - 67 degrees F, C111 - 65 degrees F; C107 - 69 degrees F; C106 - 61 degrees F; C105 - 67 degrees F, C104 - 68 degrees F; C103 - 64 degrees F; C101 - 66 degrees F; C100 - 62 degrees F, C102 - 65 degrees F; C108 - 68 degrees F; C109 - 64 degrees F; C110 - 65 degrees F, C116 - 66 degrees F; C117 - 58 degrees F. According to the Guidance to Surveyors for this requirement found in Appendix PP of the CMS State Operations Manual, ""'Comfortable and safe temperature levels' means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia or susceptibility to respiratory ailments and colds. ... For facilities certified after October 1, 1990, ... the temperatures may fall below 71 (symbol for degrees) F for facilities in areas of the country where that temperature is exceeded only during brief episodes of unseasonably cold weather (minimum temperature must still be maintained at a sufficient level to minimize risk of hypothermia and susceptibility to loss of body heat, respiratory ailments and cold). ..."" - c) Resident room ambient air temperatures were taken again between the hours of 8:30 a.m. to 9:15 a.m. on 10/06/10. At this time, forty-four (44) of forty-eight (48) occupied resident rooms tested were found below 70 degrees F, and twenty (20) of forty-eight (48) occupied resident rooms were below 65 degrees F. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/05/10, measured at 11:59 p.m., was 41 degrees F. The outside ambient air temperature, during the time of testing resident rooms on the morning of 10/06/10, was 46 degrees F. Ambient temperatures of occupied resident rooms, measured on 10/06/10 between 8:30 a.m. to 9:15 a.m., were as follows: B331 - 66 degrees F; B325 - 62 degrees F; B323 - 69 degrees F; B321 - 69 degrees F; B315 - 67 degrees F; B313 - 67 degrees F; B311 - 61 degrees F; B310 - 65 degrees F; B324 - 68 degrees F; B328 - 64 degrees F; B330 - 61 degrees F; C314 - 61 degrees F; C313 - 69 degrees F; C312 - 67 degrees F; C311 - 64 degrees F; C307 - 63 degrees F; C306 - 63 degrees F; C305 - 57 degrees F; C303 - 67 degrees F; C301 - 66 degrees F; C300 - 64 degrees F; C302 - 68 degrees F; C309 - 65 degrees F; C310 - 66 degrees F; B127 - 62 degrees F; B125 - 67 degrees F; B123 - 68 degrees F; B119 - 69 degrees F; B117 - 70 degrees F; B113 - 68 degrees F; B122 - 62 degrees F; B124 - 64 degrees F; B126 - 59 degrees F; B128 - 61 degrees F; C114 - 62 degrees F; C112 - 71 degrees F; C107 - 65 degrees F; C106 - 63 degrees F; C105 - 64 degrees F; C103 - 68 degrees F; C101 - 67 degrees F; C100 - 62 degrees F; C102 - 66 degrees F; C108 - 68 degrees F; C109 - 67 degrees F; C110 - 71 degrees F; C116 - 60 degrees F; C117 - 66 degrees F. d) A review of the National Weather Service's extended seven (7) day forecast for the Beckley area, for 10/06/10 through 10/12/10, revealed low temperatures ranging from 40 to 49 degrees F. With the boilers not operational, the facility could not maintain safe and comfortable environment for residents to prevent the risk of hypothermia. .",2014-02-01
11495,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2010-10-07,224,K,,,50Z111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of ambient air temperatures measured by a life-safety code (LSC) surveyor from the Office of Health Facility Licensure and Certification (OHFLAC), information from the National Weather Service, review of resident body temperatures, review of the facility's 10/01/10 contingency plan entitled ""Heating back up plan"", review of National Institutes of Health (NIH) news release dated 01/16/09 entitled ""Hypothermia: A Cold Weather Risk for Older People"", review of facility documents, review of information on hypothermia from the Centers for Disease Control and Prevention (CDC), review of an article entitled ""Hypothermia"" (06/09/09) by the Mayo Foundation for Medical Education and Research (MFMER), medical record review, review of Appendix PP of the Centers for Medicare & Medicaid Services (CMS) State Operations Manual, and staff interview, the facility failed to provide goods and services to avoid physical harm, by failing to provide a reliable source of heat to maintain safe indoor temperatures and ensure residents were safe from developing hypothermia. The facility's heating boiler system, utilized to heat the common areas and resident rooms, failed to pass inspection on and was ""red-tagged"" (prohibiting the use of the boiler system until defects in the system were corrected) during inspections on 08/06/10 and 08/09/10. The facility's governing body failed to obtain the necessary supplies and services to repair and/or replace this boiler system prior to the cold weather experienced in the area on 10/05/10. The facility's contingency plan entitled ""Heating back up plan"" found the plan consisted of purchasing twenty (20) portable space heaters; this number was not sufficient to supply heat to sixty-five (65) unheated rooms occupied by eighty-one (81) residents currently in the facility. The contingency plan was inadequate to ensure the residents' environment remained at safe and comfortable temperature levels. This failure resulted in the ambient air temperatures in resident rooms falling to unacceptably low levels, placing sixteen (16) of eighty-one (81) facility residents in immediate jeopardy of injury or death from hypothermia or other cold-related complications. The NIH warns in their 01/15/09 newsletter: ""... Older people also are at risk for hypothermia because their body's response to cold can be diminished by certain illnesses such as diabetes and some medicines, including over-the-counter cold remedies. In addition, older adults may be less active and generate less body heat. As a result, they can develop hypothermia even after exposure to relatively mild cold weather or a small drop in temperature... take his or her temperature. If it's 96 degrees or lower, call 911... Even mildly cool homes with temperatures from 60 to 65 degrees can trigger hypothermia in older people."" An article by the MFMER dated 06/09/09 and entitled ""Hypothermia"", states, ""Hypothermia isn't always the result of exposure to extremely cold outdoor temperatures. An older person may develop mild hypothermia after prolonged exposure to indoor temperatures that would be tolerable to a younger or healthier adult - for example, temperatures in a poorly heated home or in an air-conditioned home."" The MFMER article identified risk factors associated with developing hypothermia to include age [AGE] years or older, mental impairment, certain medical conditions (e.g., [MEDICAL CONDITIONS] ([MEDICAL CONDITION]), severe arthritis, Parkinson ' s disease, spinal cord injuries, disorders that affect sensation in the extremities (including [MEDICAL CONDITION] in diabetics), dehydration, and any condition that limits activity or restrains the normal flow of blood), and the use of certain medications (e.g., antipsychotics). On 10/06/10 at 12:15 p.m., it was determined that residents had been sleeping in rooms with an ambient air temperature as low as 59 degrees Fahrenheit (F). Sixteen (16) facility residents, who were positive for one (1) or more risk factors for hypothermia and who had extended exposure to these unsafe temperatures, were determined to have sustained a drop in their average body temperatures ranging from 0.7 degree F to 2.2 degrees F. The facility assessed these sixteen (16) residents as having body temperatures as low as 95.8 degrees F, placing them at risk for hypothermia. Information on hypothermia from CDC states: ""Hypothermia occurs when the body temperature is less than 95 degrees. If persons exposed to excessive cold are unable to generate enough heat (e.g., through shivering) to maintain a body temperature of 98.6 degrees their organs (e.g., brain heart or kidneys) can malfunction."" The administrator was informed, at 12:15 p.m. on 10/06/10, that the facility's failure to provide a reliable source of heat to resident rooms placed more than an isolated number of residents in immediate jeopardy of injury or death, due to the potential for developing hypothermia. The immediate jeopardy was abated at 8:35 p.m. on 10/06/10, following the purchase and placement of an adequate supply of portable electric space heaters to serve all occupied resident rooms, the development and implementation of a monitoring system to assess ambient air temperature and resident body temperatures, and the transfer of some of the residents from an unheated floor to a floor supplied by heat. Upon removal of the immediate jeopardy, a deficient practice remained with the potential of more than minimal harm to more than an isolated number of residents until such time as the facility obtained a safe and reliable heating system without the use of portable electric space heaters. Resident identifiers: #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, #64, and #15. Facility census: 81. Findings include: a) Residents #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, #64, and #15 Interview with the facility's administrator and the maintenance director, on 10/04/10 at approximately 1:40 p.m., revealed the facility's heating boiler system was in need of repair. The boilers intended to heat the resident rooms and common areas had been inspected by a boiler inspector and were ""red tagged"" as not operational (prohibiting the use of the boiler system until defects in the system were corrected) during inspections dated 08/06/10 and 08/09/10. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/04/10, measured at 3:35 a.m., was 43 degrees F. Ambient air temperatures of resident rooms were taken by the LSC surveyor, accompanied by a licensed practical nurse (LPN - Employee #158), between the hours of 5:30 a.m. to 6:35 a.m. on 10/05/10. Fifty-eight (58) of sixty-five (65) occupied resident rooms were found to be below 70 degrees F, and nineteen (19) of sixty-five (65) occupied resident room were found to be below 65 degrees F, which is below the temperature range of 71 to 81 degrees for safety and comfort established at 42 CFR 483.15(h)(6). (Note the outside ambient air temperature during this testing of resident room temperatures was 49 degrees F. Review of the Guidance to Surveyors for 42 CFR 483.15(h)(6), found in Appendix PP of the CMS State Operations Manual, revealed, ""'Comfortable and safe temperature levels' means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia or susceptibility to respiratory ailments and colds. ... For facilities certified after October 1, 1990, ... the temperatures may fall below 71 (symbol for degrees) F for facilities in areas of the country where that temperature is exceeded only during brief episodes of unseasonably cold weather (minimum temperature must still be maintained at a sufficient level to minimize risk of hypothermia and susceptibility to loss of body heat, respiratory ailments and cold). ..."" This determination resulted in a finding of substandard quality of care for a failure to provide comfortable and safe temperature levels facility-wide. (See citation at F257 for additional details.) This health facility nurse surveyor was brought in on the morning of 10/05/10, to assist the LSC surveyor in conducting a partial extended survey. - Upon arrival on 10/05/10 at 10:05 a.m., the nurse surveyor observed the hallways and resident rooms on the first floor to be uncomfortably chilly. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/05/10, measured at 11:59 p.m., was 41 degrees F. An interview with the LSC surveyor revealed the ambient air temperature in resident rooms on the first and other occupied floors was registering below 65 degrees F. Resident room ambient air temperatures, taken between the hours of 8:30 a.m. to 9:15 a.m. on 10/06/10, found forty-four (44) of forty-eight (48) occupied resident rooms tested were found below 70 degrees F, and twenty (20) of forty-eight (48) occupied resident rooms were below 65 degrees F. (Note the outside ambient air temperature during this testing of resident room temperatures was 46 degrees F.) The administrator (Employee #10) was present. When asked if staff was taking residents' body temperatures and assessing for signs and symptoms of hypothermia due to the excessively cool temperatures, the administrator stated staff was not taking residents' body temperatures. At this time, the nurse surveyor requested of the administrator that all residents' body temperatures be taken. Review of the residents' body temperatures, as measured by facility staff, found three (3) residents with temperatures below 97 degrees F. A review of the past history of body temperatures for these three (3) residents (Residents #12, #36, and #6) found this was not unusual for these residents. The administrator stated the facility had purchased portable electric space heaters to place throughout the facility and extra blankets for resident use. It was not found that residents were in danger of suffering from hypothermia or other cold-related complications at this time. -- The NIH warns in their 01/15/09 newsletter: ""... Older people also are as risk for hypothermia because their body's response to cold can be diminished by certain illnesses such as diabetes and some medicines, including over-the-counter cold remedies. In addition, older adults may be less active and generate less body heat. As a result, they can develop hypothermia even after exposure to relatively mild cold weather or a small drop in temperature... take his or her temperature. If it's 96 degrees or lower, call 911... Even mildly cool homes with temperatures from 60 to 65 degrees can trigger hypothermia in older people."" The CDC states, ""Hypothermia occurs when the body temperature is less than 95 degrees. If persons exposed to excessive cold are unable to generate enough heat (e.g., through shivering) to maintain a body temperature of 98.6 degrees their organs (e.g., brain heart or kidneys) can malfunction."" An article by the MFMER titled ""Hypothermia"" (06/09/09) ( ) noted, ""Hypothermia isn't always the result of exposure to extremely cold outdoor temperatures. An older person may develop mild hypothermia after prolonged exposure to indoor temperatures that would be tolerable to a younger or healthier adult - for example, temperatures in a poorly heated home or in an air-conditioned home."" The MFMER article also identifies the following risk factors associated with developing hypothermia: ""- Older age. People age 65 and older are more vulnerable to hypothermia for a number of reasons. The body's ability to regulate temperature and to sense cold may lessen with age. Older people are also more likely to have a medical condition that affects temperature regulation. Some older adults may not be able to communicate when they are cold or may not be mobile enough to get to a warm location. ... ""- Mental impairment. People with a mental illness, dementia or another condition that impairs judgment may not dress appropriately for the weather or understand the risk of cold weather. People with dementia may wander from home or get lost easily, making them more likely to be stranded outside in cold or wet weather. ... ""- Certain medical conditions. Some health disorders affect your body's ability to regulate body temperature. Examples include underactive [MEDICAL CONDITION] [MEDICAL CONDITION], stroke, severe arthritis, [MEDICAL CONDITION], trauma, spinal cord injuries, burns, disorders that affect sensation in your extremities (for example, nerve damage in the feet of people with diabetes), dehydration and any condition that limits activity or restrains the normal flow of blood. ... ""- Medications. A number of antipsychotic drugs and sedatives can impair the body's ability to regulate its temperature."" -- Upon return to the facility at 8:45 a.m. on 10/06/10, a request was again made for assessments of each resident's body temperature. Upon review of the body temperatures and conference with the LSC surveyor, it was found that residents had slept in rooms as cold as 59 degrees F, and sixteen (16) cognitively and/or physically impaired residents sustained a reduction in their body temperatures as much as 2.2 degrees F (Residents #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, and #64). The director of nursing (DON - Employee #87) was asked to provide a three-month summary of the body temperatures of these sixteen (16) residents to establish an average baseline body temperature for each individual. A tour of the facility found portable electric space heaters had been placed in the resident hallways, and the corridor doors to the residents' rooms were left open. However, the facility had not purchased enough portable electric space heaters to place one (1) in each of the occupied resident rooms, to assure the ambient air temperature remained at a safe level while residents were sleeping. A random check with the LSC surveyor found the temperatures of resident rooms to be 59 degrees F, 61 degrees F, 62 degrees F, and 64 degrees F. A review of the residents' body temperatures, taken on the morning of 10/06/10 and compared with their average baseline body temperatures over the preceding three-month period, found the following: 1. Resident #50 Resident #50's average body temperature was 98.7 degrees F. His body temperature, on the morning of 10/06/10, had dropped to 96.5 degrees F, a difference of 2.2 degrees F. His ambient room temperature was 62 degrees F. Resident #50's most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of 07/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. 2. Resident #37 Resident #37's average body temperature was 98.2 degrees F. Her body temperature, on the morning of 10/06/10, was determined to be 96.1 degrees F, a reduction of 2.1 degrees F. Her ambient room temperature was 64 degrees F. Her most recent MDS, a quarterly with an ARD of 08/02/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required extensive physical assistance with bed mobility, was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. 3. Resident #47 Resident #47's average body temperature was 98.3 degrees F. His body temperature, on the morning of 10/06/10, was 96.9 degrees F, a reduction of 1.3 degrees F. The ambient air temperature in his room was 61 degrees F. His most recent MDS, a comprehensive annual assessment with an ARD of 07/26/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required limited physical assistance with bed mobility and extensive physical assistance with transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics. 4. Resident #75 Resident #75's average body temperature was 97.9 degrees F. His body temperature, on the morning of 10/06/10, was 96.5 degrees F, a reduction of 1.4 degrees F. The ambient air temperature in his room was 59 degrees F. His most recent MDS, an annual with an ARD of 07/19/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required limited physical assistance with bed mobility, he was totally dependent on staff for transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics and antidepressants daily. 5. Resident #42 Resident #42's average body temperature was 98.7 degrees F. Her body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of her room was 62 degrees F. Her most recent MDS, a quarterly with an ARD of 08/09/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. 6. Resident #82 Resident #82's average body temperature was 98.6 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of her room was 63 degrees F. Her most recent MDS, a quarterly with an ARD of 08/30/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required limited physical assistance with bed mobility and extensive physical assistance with transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics, anxiolytics, and antidepressants daily. 7. Resident #49 Resident #49's average body temperature was 98.3 degrees F. His body temperature, on the morning of 10/06/10, was 96.4 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of his room was 66 degrees F. Resident #49's most recent MDS, a quarterly with an ARD of 08/08/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were severely impaired, he was totally dependent on staff for bed mobility and transferring, and he did not ambulate during the assessment reference period. 8. Resident #52 Resident #52's average body temperature was 98.4 degrees F. Her body temperature, on the morning of 10/06/10, was 96.6 degrees F, a reduction of 1.8 degrees F. The ambient air temperature in her room was 67 degrees F. Her most recent MDS, a quarterly with an ARD of 09/10/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were moderately impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics daily. 9. Resident #83 Resident #83's average body temperature was 98.2 degrees F. His body temperature, on the morning of 10/06/10, was 96.5 degrees F, a reduction of 1.7 degrees F. The ambient air temperature in his room was 66 degrees F. His most recent MDS, a quarterly with an ARD of 09/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required extensive physical assistance with bed mobility, he was totally dependent on staff for transferring, and he did not ambulate during the assessment reference period. 10. Resident #44 Resident #44's average body temperature was 98.3 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 1.7 degrees F. The ambient air temperature in her room was 67 degrees F. Her most recent MDS, a quarterly with an ARD of 09/20/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. 11. Resident #11 Resident #11's average body temperature was 98.3 degrees F. Her body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.5 degrees F. Her ambient room temperature was 61 degrees F. Her most recent MDS, a comprehensive significant change in status assessment with an ARD of 07/26/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were moderately impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics, anxiolytics, and antidepressants daily. 12. Resident #68 Resident #68's average body temperature was 97.3 degrees F. Her body temperature, on the morning of 10/06/10, was 95.8 degrees F, a reduction of 1.5 degrees F. Her ambient room temperature was 69 degrees F. Her most recent MDS, an annual with an ARD of 07/26/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. She was also receiving anxiolytics and antidepressants daily. 13. Resident #39 Resident #39's average body temperature was 98.2 degrees F. His body temperature, on the morning of 10/06/10, was 96.9 degrees F, a reduction of 1.3 degrees F. The ambient air temperature of his room was 67 degrees F. His most recent MDS, a quarterly with an ARD of 07/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. He was also receiving antipsychotics, antidepressants, and anxiolytics daily. 14. Resident #41 Resident #41's average body temperature was 97.5 degrees F. Her body temperature, on the morning of 10/06/10, was 96.4 degrees F, a reduction of 1.1 degrees F. The ambient air temperature of her room was 64 degrees F. Her most recent MDS, an annual with an ARD of 08/16/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she was totally dependent on staff for bed mobility and transferring, and she did not ambulate during the assessment reference period. 15. Resident #64 Resident #64's average body temperature was 97.9 degrees F. His body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.1 degrees F. The ambient air temperature of his room was 68 degrees F. His most recent MDS, a quarterly with an ARD of 08/23/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were severely impaired, he required extensive physical assistance with transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics, antidepressants, and anxiolytics daily. 16. Resident #15 Resident #15's average body temperature was 97.4 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 0.7 degree F. Her ambient room temperature was 66 degrees F. Her most recent MDS, a quarterly with an ARD of 09/23/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. She was also receiving antipsychotics daily. -- Following the analysis of residents' body temperatures, review of ambient air temperatures, and conference with the LSC surveyor and program manager, it was determined the facility's failure to obtain the necessary repairs and/or replacement of the boiler heating system serving the resident rooms and common areas, failure to obtain sufficient portable electric space heaters to keep resident sleeping areas at safe temperatures, and failure to assure the residents' body temperatures remained at normal levels constituted an immediate threat to the life and health of more than an isolated number of residents living in the facility. The immediate jeopardy was abated at 8:35 p.m. on 10/06/10, following the purchase and placement of an adequate supply of portable electric space heaters to serve each resident rooms and the common areas, the development and implementation of a monitoring system to assess ambient air temperature and resident body temperatures, and the transfer of some of the residents from an unheated floor to a floor supplied by heat. It was determined that a deficient practice remained with the potential of more than minimal harm to more than an isolated number of residents until such time as the facility obtained a safe and reliable heating system. .",2014-02-01
11496,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2010-10-07,493,K,,,50Z111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of ambient air temperatures measured by a life-safety code (LSC) surveyor from the Office of Health Facility Licensure and Certification (OHFLAC), information from the National Weather Service, review of resident body temperatures, review of the facility's 10/01/10 contingency plan entitled ""Heating back up plan"", review of National Institutes of Health (NIH) news release dated 01/16/09 entitled ""Hypothermia: A Cold Weather Risk for Older People"", review of facility documents, review of information on hypothermia from the Centers for Disease Control and Prevention (CDC), review of an article entitled ""Hypothermia"" (06/09/09) by the Mayo Foundation for Medical Education and Research (MFMER), medical record review, review of Appendix PP of the Centers for Medicare & Medicaid Services (CMS) State Operations Manual, and staff interview, the facility's governing body failed to obtain the necessary supplies and services to repair and/or replace this boiler system prior to the cold weather experienced in the area on 10/05/10. The facility's heating boiler system, utilized to heat the common areas and resident rooms, failed to pass inspection on and was ""red-tagged"" (prohibiting the use of the boiler system until defects in the system were corrected) during inspections on 08/06/10 and 08/09/10. The governing body, possessing the authority to approve and allocate funds for the maintenance of the heating system for this facility, was aware of significant problems with the heating boiler system as early as August 2009. The governing body was also aware the facility's heating boiler system failed to pass inspections in August 2010 and did not act to correct the identified problems prior to a complaint survey beginning on 10/04/10. The failure of the governing body to authorize funding for the necessary repair and/or replacement of the malfunctioning heating boiler system, or to provide for an acceptable alternate heat source, in a timely manner resulted in findings of immediate jeopardy and substandard quality of care. It was determined, on 10/06/10 at 12:15 p.m., that residents residing in this unheated facility were placed in immediate jeopardy of harm or death related to the potential for developing hypothermia or other cold-related complications. Residents were found sleeping in rooms with ambient air temperatures as low as 59 degrees Fahrenheit (F). Sixteen (16) residents, who exhibited one (1) or more risk factors for developing hypothermia, were found to have sustained a drop in their average body temperatures ranging from 0.7 degree F to 2.2 degrees F related to exposure to less than safe indoor temperatures. The governing body of this facility was ultimately responsible for the procurement, approval, and allocation of funding to maintain and ensure a safe and reliable heating system for this facility, as this entity alone possessed the authority to approve necessary repairs and/or replacement of this malfunctioning heating system. This practice affected sixteen (16) of eighty-one (81) residents currently residing in the facility. Resident identifiers: #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, #64, and #15. Findings include: a) Residents #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, #64, and #15 Interview with the facility's administrator and the maintenance director, on 10/04/10 at approximately 1:40 p.m., revealed the facility's heating boiler system was in need of repair. The boilers intended to heat the resident rooms and common areas had been inspected by a boiler inspector and were ""red tagged"" as not operational (prohibiting the use of the boiler system until defects in the system were corrected) during inspections dated 08/06/10 and 08/09/10. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/04/10, measured at 3:35 a.m., was 43 degrees F. Ambient air temperatures of resident rooms were taken by the LSC surveyor, accompanied by a licensed practical nurse (LPN - Employee #158), between the hours of 5:30 a.m. to 6:35 a.m. on 10/05/10. Fifty-eight (58) of sixty-five (65) occupied resident rooms were found to be below 70 degrees F, and nineteen (19) of sixty-five (65) occupied resident room were found to be below 65 degrees F, which is below the temperature range of 71 to 81 degrees for safety and comfort established at 42 CFR 483.15(h)(6). (Note the outside ambient air temperature during this testing of resident room temperatures was 49 degrees F. Review of the Guidance to Surveyors for 42 CFR 483.15(h)(6), found in Appendix PP of the CMS State Operations Manual, revealed, ""'Comfortable and safe temperature levels' means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia or susceptibility to respiratory ailments and colds. ... For facilities certified after October 1, 1990, ... the temperatures may fall below 71 (symbol for degrees) F for facilities in areas of the country where that temperature is exceeded only during brief episodes of unseasonably cold weather (minimum temperature must still be maintained at a sufficient level to minimize risk of hypothermia and susceptibility to loss of body heat, respiratory ailments and cold). ..."" This determination resulted in a finding of substandard quality of care for a failure to provide comfortable and safe temperature levels facility-wide. (See citation at F257 for additional details.) This health facility nurse surveyor was brought in on the morning of 10/05/10, to assist the LSC surveyor in conducting a partial extended survey. - Upon arrival on 10/05/10 at 10:05 a.m., the nurse surveyor observed the hallways and resident rooms on the first floor to be uncomfortably chilly. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/05/10, measured at 11:59 p.m., was 41 degrees F. An interview with the LSC surveyor revealed the ambient air temperature in resident rooms on the first and other occupied floors was registering below 65 degrees F. Resident room ambient air temperatures, taken between the hours of 8:30 a.m. to 9:15 a.m. on 10/06/10, found forty-four (44) of forty-eight (48) occupied resident rooms tested were found below 70 degrees F, and twenty (20) of forty-eight (48) occupied resident rooms were below 65 degrees F. (Note the outside ambient air temperature during this testing of resident room temperatures was 46 degrees F.) The administrator (Employee #10) was present. When asked if staff was taking residents' body temperatures and assessing for signs and symptoms of hypothermia due to the excessively cool temperatures, the administrator stated staff was not taking residents' body temperatures. At this time, the nurse surveyor requested of the administrator that all residents' body temperatures be taken. Review of the residents' body temperatures, as measured by facility staff, found three (3) residents with temperatures below 97 degrees F. A review of the past history of body temperatures for these three (3) residents (Residents #12, #36, and #6) found this was not unusual for these residents. The administrator stated the facility had purchased portable electric space heaters to place throughout the facility and extra blankets for resident use. It was not found that residents were in danger of suffering from hypothermia or other cold-related complications at this time. -- The NIH warns in their 01/15/09 newsletter: ""... Older people also are as risk for hypothermia because their body's response to cold can be diminished by certain illnesses such as diabetes and some medicines, including over-the-counter cold remedies. In addition, older adults may be less active and generate less body heat. As a result, they can develop hypothermia even after exposure to relatively mild cold weather or a small drop in temperature... take his or her temperature. If it's 96 degrees or lower, call 911... Even mildly cool homes with temperatures from 60 to 65 degrees can trigger hypothermia in older people."" The CDC states, ""Hypothermia occurs when the body temperature is less than 95 degrees. If persons exposed to excessive cold are unable to generate enough heat (e.g., through shivering) to maintain a body temperature of 98.6 degrees their organs (e.g., brain heart or kidneys) can malfunction."" An article by the MFMER titled ""Hypothermia"" (06/09/09) ( ) noted, ""Hypothermia isn't always the result of exposure to extremely cold outdoor temperatures. An older person may develop mild hypothermia after prolonged exposure to indoor temperatures that would be tolerable to a younger or healthier adult - for example, temperatures in a poorly heated home or in an air-conditioned home."" The MFMER article also identifies the following risk factors associated with developing hypothermia: ""- Older age. People age 65 and older are more vulnerable to hypothermia for a number of reasons. The body's ability to regulate temperature and to sense cold may lessen with age. Older people are also more likely to have a medical condition that affects temperature regulation. Some older adults may not be able to communicate when they are cold or may not be mobile enough to get to a warm location. ... ""- Mental impairment. People with a mental illness, dementia or another condition that impairs judgment may not dress appropriately for the weather or understand the risk of cold weather. People with dementia may wander from home or get lost easily, making them more likely to be stranded outside in cold or wet weather. ... ""- Certain medical conditions. Some health disorders affect your body's ability to regulate body temperature. Examples include underactive [MEDICAL CONDITION] [MEDICAL CONDITION], stroke, severe arthritis, [MEDICAL CONDITION], trauma, spinal cord injuries, burns, disorders that affect sensation in your extremities (for example, nerve damage in the feet of people with diabetes), dehydration and any condition that limits activity or restrains the normal flow of blood. ... ""- Medications. A number of antipsychotic drugs and sedatives can impair the body's ability to regulate its temperature."" -- Upon return to the facility at 8:45 a.m. on 10/06/10, a request was again made for assessments of each resident's body temperature. Upon review of the body temperatures and conference with the LSC surveyor, it was found that residents had slept in rooms as cold as 59 degrees F, and sixteen (16) cognitively and/or physically impaired residents sustained a reduction in their body temperatures as much as 2.2 degrees F (Residents #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, and #64). The director of nursing (DON - Employee #87) was asked to provide a three-month summary of the body temperatures of these sixteen (16) residents to establish an average baseline body temperature for each individual. A tour of the facility found portable electric space heaters had been placed in the resident hallways, and the corridor doors to the residents' rooms were left open. However, the facility had not purchased enough portable electric space heaters to place one (1) in each of the occupied resident rooms, to assure the ambient air temperature remained at a safe level while residents were sleeping. A random check with the LSC surveyor found the temperatures of resident rooms to be 59 degrees F, 61 degrees F, 62 degrees F, and 64 degrees F. A review of the residents' body temperatures, taken on the morning of 10/06/10 and compared with their average baseline body temperatures over the preceding three-month period, found the following: 1. Resident #50 Resident #50's average body temperature was 98.7 degrees F. His body temperature, on the morning of 10/06/10, had dropped to 96.5 degrees F, a difference of 2.2 degrees F. His ambient room temperature was 62 degrees F. Resident #50's most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of 07/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. 2. Resident #37 Resident #37's average body temperature was 98.2 degrees F. Her body temperature, on the morning of 10/06/10, was determined to be 96.1 degrees F, a reduction of 2.1 degrees F. Her ambient room temperature was 64 degrees F. Her most recent MDS, a quarterly with an ARD of 08/02/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required extensive physical assistance with bed mobility, was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. 3. Resident #47 Resident #47's average body temperature was 98.3 degrees F. His body temperature, on the morning of 10/06/10, was 96.9 degrees F, a reduction of 1.3 degrees F. The ambient air temperature in his room was 61 degrees F. His most recent MDS, a comprehensive annual assessment with an ARD of 07/26/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required limited physical assistance with bed mobility and extensive physical assistance with transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics. 4. Resident #75 Resident #75's average body temperature was 97.9 degrees F. His body temperature, on the morning of 10/06/10, was 96.5 degrees F, a reduction of 1.4 degrees F. The ambient air temperature in his room was 59 degrees F. His most recent MDS, an annual with an ARD of 07/19/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required limited physical assistance with bed mobility, he was totally dependent on staff for transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics and antidepressants daily. 5. Resident #42 Resident #42's average body temperature was 98.7 degrees F. Her body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of her room was 62 degrees F. Her most recent MDS, a quarterly with an ARD of 08/09/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. 6. Resident #82 Resident #82's average body temperature was 98.6 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of her room was 63 degrees F. Her most recent MDS, a quarterly with an ARD of 08/30/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required limited physical assistance with bed mobility and extensive physical assistance with transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics, anxiolytics, and antidepressants daily. 7. Resident #49 Resident #49's average body temperature was 98.3 degrees F. His body temperature, on the morning of 10/06/10, was 96.4 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of his room was 66 degrees F. Resident #49's most recent MDS, a quarterly with an ARD of 08/08/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were severely impaired, he was totally dependent on staff for bed mobility and transferring, and he did not ambulate during the assessment reference period. 8. Resident #52 Resident #52's average body temperature was 98.4 degrees F. Her body temperature, on the morning of 10/06/10, was 96.6 degrees F, a reduction of 1.8 degrees F. The ambient air temperature in her room was 67 degrees F. Her most recent MDS, a quarterly with an ARD of 09/10/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were moderately impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics daily. 9. Resident #83 Resident #83's average body temperature was 98.2 degrees F. His body temperature, on the morning of 10/06/10, was 96.5 degrees F, a reduction of 1.7 degrees F. The ambient air temperature in his room was 66 degrees F. His most recent MDS, a quarterly with an ARD of 09/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required extensive physical assistance with bed mobility, he was totally dependent on staff for transferring, and he did not ambulate during the assessment reference period. 10. Resident #44 Resident #44's average body temperature was 98.3 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 1.7 degrees F. The ambient air temperature in her room was 67 degrees F. Her most recent MDS, a quarterly with an ARD of 09/20/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. 11. Resident #11 Resident #11's average body temperature was 98.3 degrees F. Her body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.5 degrees F. Her ambient room temperature was 61 degrees F. Her most recent MDS, a comprehensive significant change in status assessment with an ARD of 07/26/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were moderately impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics, anxiolytics, and antidepressants daily. 12. Resident #68 Resident #68's average body temperature was 97.3 degrees F. Her body temperature, on the morning of 10/06/10, was 95.8 degrees F, a reduction of 1.5 degrees F. Her ambient room temperature was 69 degrees F. Her most recent MDS, an annual with an ARD of 07/26/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. She was also receiving anxiolytics and antidepressants daily. 13. Resident #39 Resident #39's average body temperature was 98.2 degrees F. His body temperature, on the morning of 10/06/10, was 96.9 degrees F, a reduction of 1.3 degrees F. The ambient air temperature of his room was 67 degrees F. His most recent MDS, a quarterly with an ARD of 07/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. He was also receiving antipsychotics, antidepressants, and anxiolytics daily. 14. Resident #41 Resident #41's average body temperature was 97.5 degrees F. Her body temperature, on the morning of 10/06/10, was 96.4 degrees F, a reduction of 1.1 degrees F. The ambient air temperature of her room was 64 degrees F. Her most recent MDS, an annual with an ARD of 08/16/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she was totally dependent on staff for bed mobility and transferring, and she did not ambulate during the assessment reference period. 15. Resident #64 Resident #64's average body temperature was 97.9 degrees F. His body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.1 degrees F. The ambient air temperature of his room was 68 degrees F. His most recent MDS, a quarterly with an ARD of 08/23/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were severely impaired, he required extensive physical assistance with transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics, antidepressants, and anxiolytics daily. 16. Resident #15 Resident #15's average body temperature was 97.4 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 0.7 degree F. Her ambient room temperature was 66 degrees F. Her most recent MDS, a quarterly with an ARD of 09/23/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. She was also receiving antipsychotics daily. -- Following the analysis of residents' body temperatures, review of ambient air temperatures, and conference with the LSC surveyor and program manager, it was determined the facility's failure to obtain the necessary repairs and/or replacement of the boiler heating system serving the resident rooms and common areas, failure to obtain sufficient portable electric space heaters to keep resident sleeping areas at safe temperatures, and failure to assure the residents' body temperatures remained at normal levels constituted an immediate threat to the life and health of more than an isolated number of residents living in the facility. The immediate jeopardy was abated at 8:35 p.m. on 10/06/10, following the purchase and placement of an adequate supply of portable electric space heaters to serve each resident rooms and the common areas, the development and implementation of a monitoring system to assess ambient air temperature and resident body temperatures, and the transfer of some of the residents from an unheated floor to a floor supplied by heat. It was determined that a deficient practice remained with the potential of more than minimal harm to more than an isolated number of residents until such time as the facility obtained a safe and reliable heating system. -- b) Review of facility documents found a request from the facility, dated 08/24/09, to replace a boiler which had been in operation since 10/94. The document from the governing body stated the funds were available and were awaiting ""your okay"". On 08/25/09, the chief operations officer (COO) of the governing body replied, ""I don't see anything happening with this project until next summer so we would need to be able to fire the old boiler one more winter..."" The facility replied, on 08/26/09, with, ""Yes sir, to be honest I was afraid that we were not going to make it last winter and we almost did not, this boiler blew tubes and went down at least ten times last winter, every time we blow a tube the steam fills the boiler and then is followed by the cold water supplying the boiler... I do not believe that this boiler will last through the winter if we were able to get all of this repair work completed before cold sets in, I honestly believe that at this point we need to try to get a new boiler just like this one and switch them out..."" As of the immediate jeopardy and substandard quality of care finding on 10/06/10, there was no indication the governing body had made any arrangements for the replacement of the boiler system, or the acquisition of an acceptable alternate heat source, to ensure residents were provided a safe and comfortable environment for the winter of 2010. .",2014-02-01
11497,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2010-10-07,323,D,,,50Z111,". Based on random observation and staff interview, the facility failed to assure the resident environment remained as free of accident hazards as is possible. A nurse left a 50 cc bottle of liquid Dilantin on top of her medication cart, and left the cart parked and unsupervised at the unlocked nursing station. Resident #68 was observed to have unfettered access to the medication for approximately five (5) minutes. Facility census: 81. Findings include: a) Resident #68 Observations of the resident environment, on 10/06/10 at 8:08 p.m., noted Resident #68 wandering the resident hallway. She was observed to enter the unlocked nursing station and approach the medication cart parked there. No staff members were visible in the hallway or at the nursing station. The resident was approached and an attempt was made to redirect the resident's attention away from a bottle of medication sitting on top of the cart. The resident made inappropriate answers to questions but followed this surveyor out of the nursing station. After approximately five (5) minutes, a nurse was observed to exit a resident's room with a treatment cart. She was informed that Resident #68 was found unsupervised in the nursing station where a bottle of liquid medication was noted to be sitting on top of a medication cart. When asked what the medication was, the nurse (Employee #168) stated the bottle contained 50 cc of Dilantin 125/5ml. She stated she had not been given a key to the medication room to secure the medication. .",2014-02-01
11498,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2010-12-02,431,B,,,50Z112,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on random observation, staff interview, and review of drug manufacturer's information, the facility failed to assure all medications were maintained in safe and secure storage. This deficient practice affected two (2) of four (4) sampled residents. Resident identifiers: #7 and #60. Facility census: 86. Findings include: a) Resident #7 Random observations of the resident environment, on 11/29/10 at 2:10 p.m., found a 4 ounce tube of Vitamin A&D ointment lying on the windowsill of the resident's room. Interview with Resident #7 found him to be alert and oriented, and he answered questions appropriately. When asked what the tube of medication was used for, he stated, ""They rub it on me,"" while making rubbing motions around his groin area. It was noted that no residents were wandering in the hallway. Following this observation, the director of nursing (DON) was informed that the ointment had been left unsecured in the resident's room. She agreed the ointment should be secured. Review of the manufacturer's insert found no indications the ointment could cause poisoning should it be accidently ingested by a confused resident. b) Resident #60 Random observations of the facility, on 11/29/10 at 2:15 p.m., found tubes of Collagenase (utilized for treatment of [REDACTED]. It was noted that no residents were wandering in the hallway. The DON was notified of the presence of the tubes of ointment in the resident's room. She removed the ointment and agreed the medication should be secured. Review of the manufacturer's information found the following, ""No systemic or local reaction attributed to overdose has been observed in clinical investigations and clinical use..."".",2014-02-01
11499,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2011-04-26,160,D,,,NEGO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to convey the funds, and a final accounting of those funds, within thirty (30) days after the death of the resident for two (2) of three (3) residents reviewed. Resident identifiers: #60 and #48. Facility census: 77. Findings include: a) Residents #60 and #48 The facility's resident funds accounts were reviewed at 8:30 a.m. on [DATE]. The balance of personal funds being held by the facility for two (2) of three (3) deceased residents reviewed had not been released within thirty (30) days after their deaths as required. Resident #60 passed away on [DATE]. Facility records show the balance of her personal account of $34.30 was not released until [DATE]. Resident #48 passed away on [DATE]. Facility records show the balance of her personal funds of $50.00 was not released until [DATE]. During an interview with the administrator (Employee #36) on [DATE] at 9:20 a.m., she confirmed these funds had not been conveyed within the required thirty (30) days. .",2014-01-01
11500,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2011-04-26,279,D,,,NEGO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for one (1) of forty (40) Stage II sample residents, to develop a care plan to include measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs. Resident #21 was admitted for a planned short rehabilitation stay and remained in the facility after rehabilitation goals had been met. No care plan was implemented to address the resident's discharge needs. The resident also was known to be at risk for falls at the time of admission, and no care plan goals and interventions were developed to address the risk. The resident did incur additional falls. Resident identifier: #21. Facility census: 77. Findings include: a) Resident #21 1. When reviewed on 04/25/11, the medical record for Resident #21 revealed an admission date of [DATE]. According to a discharge summary report (dated 10/26/10) from the hospital where she was last admitted , this [AGE] year old female had fallen from bed in her home and sustained ""multiple bilateral lower extremity fractures"". Review of the physician's determination of capacity for this resident divulged that, at the time of admission (10/26/10), the resident's attending physician determined she did not have the capacity to understand and make health care decisions. This determination was changed on 01/03/11, when it was determined at that time that she did possess the capacity to make those decisions. An entry in social service (SS) notes, dated 11/09/10, stated: ""D/C (discharge) plans are to return home."" Again on 11/24/10, a SS note stated: ""D/c plans remain to return home. No d/c date at this time."" On 01/17/11, a SS note stated: ""She plans to rehab & return home. MPOA (medical power of attorney) states resident will be LTC (long term care)."" One (1) of two (2) minimum data set assessment (MDS) coordinators (Employee #65), when questioned on 04/25/11 at approximately 11:00 a.m. about the resident's plan to return to her home, stated the resident was occasionally confused, and Employee #65 did not feel the resident could care for herself at home, manage her diabetes, etc. She further stated she did not think the resident's family was willing to help her at home. The resident's care plan, when reviewed on 04/25/11, contained no mention of discharge and/or discharge planning for this resident on this document, which was most recently updated on 04/11/11. When reviewed again on 04/26/11, the resident's care plan had been updated to reflect the uncertainty of the resident's plan to discharge home. The facility's social worker (Employee #27), when interviewed on 04/26/11, confirmed she had not initiated any care plan related to discharge for this resident until 04/26/11. This employee further confirmed the resident's ability to make medical decisions was questionable and that a review of her capacity status had been requested. Recent calls to the resident's family / MPOA had gone unreturned, according to this employee. -- 2. The resident's individual interim plan of care, dated as completed on 10/27/10, was reviewed with respect to falls. The document stated the resident had the problem of falls due to a past history of falls. There were, however, no goals or approaches listed on the document to address this problem in an effort to prevent further falls. A physician's orders [REDACTED]. A falls investigation / root cause analysis form for this resident was noted to have been completed on 02/20/11. This document, and the information attached to it, stated the resident complained of hip pain when being re-positioned in the restorative room on the morning of 02/20/11, stating she fell out of bed the previous night and ""yelled for help"" and was assisted back to bed. Although the facility's investigation could provide no staff with knowledge of this incident, the resident received an x-ray to her right hip, which was negative for ""acute fractures"". An additional falls investigation / root cause analysis form for this resident was noted to have been completed on 03/31/11. This document, and the information attached to it, stated, ""I found resident sitting on floor between beds, she was yelling out, her alarm was on & working"". The document made no mention of the resident having been in a low bed at the time of the fall. An update to the resident's care plan was instituted on 03/31/11, stating the resident had an actual fall. Interventions at that time included: mat on floor; extensive assist with transfers; low bed; and start ""falling star"" program. The director of nursing (DON - Employee #63) was interviewed at 2:45 p.m. on 04/25/11. Following review of the resident's medical record and the above mentioned documents, the DON confirmed that no interventions to address falls were implemented at the time of admission (even though she had been hospitalized prior to her admission to the nursing home because of injuries she sustained as a result of a fall at home). Interventions were not implemented until after the resident had possibly fallen from the bed on 02/20/11 and after she had definitely fallen from the bed on 03/31/11. .",2014-01-01
11501,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2011-04-26,280,D,,,NEGO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, staff interview, and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to revise the care plans of two (2) of forty (40) Stage II sample residents, when changes occurred in their health condition and/or treatment plan. Resident #28 was a [AGE] year old female with severe contractures and a history of pressure sores. The resident's right leg was severely contracted, which caused the resident's right heel to push into the resident's buttocks. The staff had been applying heel protectors to the resident's heels to reduce pressure to these areas; the heel protectors were discontinued on 02/10/11, with no other intervention(s) added to address this unrelieved pressure against the right heel. The pressure on the heel from constant contact with buttocks resulted in a suspected deep tissue injury, which was identified on 04/03/11. At that time, the facility failed to identify this constant pressure as the cause of the pressure sore, and failed to revise her care plan to include measures to reduce / relieve this pressure until after the physical therapist was consulted on 04/19/11. Resident #41's care plan was not revised to reflect the application of a hand roll to address contractures of the resident's left hand. Facility census: 77. Findings include: a) Resident #28 Record review revealed Resident #28 was a [AGE] year old female with severe contractures and a history of pressure sores. A review of Resident #28's minimum data set assessment (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of 01/18/11, revealed the assessor identified, in Section G, that Resident #28 was totally dependent on staff for the performance of all activities of daily living and had functional limitations in range of motion in both upper and lower extremities. In Section K, the assessor noted she did not have a significant weight loss either in the previous month or in the previous six (6) months. In Section M, the assessor noted she had no unhealed pressure sores and there were no pressure ulcers present on the prior MDS, although she was at risk for developing pressure sores in the future. Review of the Braden Scale assessment (for predicting pressure sore risk) dated 01/18/11, the resident scored ""13"", indicating she was at moderate risk for developing a pressure sore. A progress note recorded by the former MDS coordinator (Employee #63), dated 01/25/11, stated (quoted as typed): ""Quarterly care plan conference held today. ... Currently skin is intact , receives preventative skin treatments Q (every) shift. Float heels when in bed, air mattress, and heel protectors. resident has multiple contracture to extremities, refuses daily to get OOB (out of bed), will agree to get out of bed on 3-11 shift approximately 2 times a week. ..."" -- The resident's care plan, dated 09/16/08 to 08/04/10, identified the following problem statement (quoted as typed): ""Potential for impaired skin due to fragile skin, history of impaired skin, incontinence, impaired mobility, at risk for UTIS (urinary tract infection),unstageable area to left heel."" (A line was drawn through ""unstageable area to left heel"", followed by ""D/C (discontinued) 10/26/10"".) This problem statement was subsequently updated with handwritten entries as follows (quoted as written): - ""Will return to Rt (right) side /p (after) repositioning and use of repositioning aides."" (This entry was not dated or signed.) - ""4-29-10 Open area on left buttocks."" (This entry was subsequently marked as ""resolved"" on 06/01/10.) - ""8-4-10 blisters to left inner big toe and right little toe outer aspect."" - ""8/8/10 Open blister on rt. shoulder."" (This entry was subsequently marked through, with no date to indicate when this was discontinued.) - ""4/1/11 I am At risk for excoriation under my breast."" - ""4/22/11 SDTI (suspected deep tissue injury) (R) (right) heel."" (According to the NPUAP, a ""suspected deep tissue injury"" is defined as: ""Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue."") The goals associated with this problem statement included (quoted as typed and/or written): ""Resident will have intact skin through the next 90 days and will develop no UTIS. Area to left heel will reso;lve prior to next review. (This goal addressing the area to the resident's left heel was discontinued on 10/26/10, after the area was resolved.) ... 4/22/11 Will resolve SDTI (R) heel /s (without) complications through next review."" The interventions associated with the above problem statement with its subsequent revisions included (quoted as typed and/or written): ""Examine skin during bathing for signs / symptoms of irritation and/or breakdown. ... Assure proper positioning in/out of bed. Utilize pillows ect. as needed. Assess skin for S/S (signs / symptoms) of breakdowns, report to MD if so noted. ... OOB (out of bed) in geri-chair with cushion daily as tolerated. Turn and reposition as indicated. Heels up while in bed. skin prep to left heel twice daily for protection. Air mattress to bed to promote wound healing, ... Change and check for incontinence upon awakening, before and after meals, before bed and prn (as needed). ... Topical treatment to (R) heel as ordered."" Notations on the care plan revealed the use of ""(h)eel protectors while in bed"" was discontinued on 02/10/11. -- A separate care plan, dated 04/04/11, contained the following ""focus area"" (quoted as typed): ""I have SDTI to my (R) heel r/t (related to)[MEDICAL CONDITIONS] with multiple joint contractures, Hx (history of) ulcers, Immobility."" The goal associated with this focus was: ""The SDTI of my (R) heel will show signs of healing and remain free from complications through review date."" The interventions planned to achieve this goal were: ""I need to turn / reposition at least every 2 hours, more often as needed or requested. I need moisturizer applied daily and PRN to my skin. ... I require low air loss mattress to my bed. ... I require supplemental protein and nutritional supplements as ordered to promote wound healing. Administer treatments as ordered. ... Administer treatments as ordered and monitor for effectiveness (skin prep (R) heel as ordered). Assess / record/ monitor wound healing weekly. ... Monitor nutritional status. ... Monitor / document / report to MD PRN changes in skin status. ..."" The care plan did not recognize as the causative factor of the pressure sore the constant pressure from the right heel's contact with the resident's buttocks, and there were no interventions to reduce / relieve this pressure. -- An interview with the director of nursing (DON - Employee #63), on 04/25/11 at 11:00 a.m., revealed the facility was told by ""corporate"" to discontinue all heel protectors, because research showed the heel protector did not help with eliminating pressure from the heel. Instead, the facility was using other methods, such as floating the heels off of the bed and pillows. The DON further stated the intervention for floating Resident #28's heels could not be achieved related to her lower extremity contractures. -- An interview with the physical therapist, on 04/25/11 at 12:00 p.m., revealed the resident received an evaluation related to a pressure (black) area on the resident's right heel. According to the physical therapist, ""The right leg is very contracted and pushes against the resident's buttocks, causing pressure. We are treating the resident with pressure-relieving heel protectors which will prevent the heel from pushing against the resident's buttocks."" -- An observation of Resident #28, on 04/25/11 at 2:10 p.m., found her in bed in her room. A nurse (Employee #52) removed the resident's blankets, and the resident was observed to have a dime-sized area of eschar on her right foot. The resident had padded heel protectors on both feet. The resident's right leg was severely twisted up around her back, with the right heel fixed against her buttocks. The left leg was also observed as severely twisted and fixed in position. Padded heel protectors were on the resident's feet. Employee #52 stated, ""The resident is very difficult to move in bed. She refuses to get out of bed frequently and becomes very agitated when turned and repositioned."" She further stated, ""I just came on full time and before that I only worked part time. I really don't know much about the resident."" The resident's care plan directed staff to float the resident's heels off of the bed; however, this observation revealed the resident's lower extremities were so severely contracted that it was not possible to float her heels off of the bed. According to the NPUAP, the presence of eschar on the resident's right heel (as seen by the nurse surveyor on 04/25/11) is consistent with the NPUAP's definition of an ""unstageable"" pressure sore: ""Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. ... Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed."" -- A review of the physical therapy evaluation dated 04/19/11 revealed, under the heading ""Reason for Referral"": ""Contracture mgmt. (management), Splint / Orthosis; Compromised skin integrity"". The long term goal for therapy was: ""Upon completion of therapy, pt (patient) will tolerate positioning wedge x 2 hrs to decrease pressure of feet on buttocks."" Under the heading ""Other Observations"" was: ""There is a nickel-sized area on her posterior right heel. It is covered with black eschar with an irregular border and red periphery. It is dry."" Under the heading ""Positioning"" was: ""Recommendations made for Equipment: Nursing recommending positioning device to relieve pressure from right heel due to a pressure area developing from heel being placed against buttocks."" Also under the heading was: ""Pt lies on either side with UEs (upper extremities) and LEs (lower extremities) contracted up into flexion. Her LEs are contracted to the extent that her feet are being pressed against her buttocks."" Review of the physical therapy weekly note dated 04/25/11 found, under the heading of ""Justification for Continued Treatment"": ""Pt was provided with padded heel protectors which demonstrated a good fit. The original positioning wedge appeared to be too large and the order was cancelled. Pt is tolerating gentle ROM (range of motion) / stretching, but occasionally will note discomfort. Continue with ROM as tolerated and monitor use of heel protectors. Also, a gel cushion has been ordered to apply to her chair for further pressure reduction."" -- An interview with the physical therapist, on 04/26/11 at 9:35 a.m., revealed a wedge was considered and was not ordered for the resident. The extra padded foot protectors were ordered and applied to keep the right heel from going against the resident's buttocks causing pressure. Some manipulations of the LE contractures allowed some extension to the contractures. The resident was unable to tolerate too much manipulation of the contracture. The physical therapist stated she was going to attempt to stretch as much as possible the contractures of the resident's lower extremities. -- A physician's progress note dated 04/15/11 stated: ""(Resident #28) developed in early April developed an area on her right heel. Initially it measured 1.2 x 1.6 centimeters areas is blackish brown in color. It is suspected to be a deep tissue injury. She has severe contractures, probably in the entire facility her contractures are worse than anyone that we have. I believe this is unavoidable because of the severe contractures. She has positioning therapy. She has been referred to physical therapy. Her pre-[MEDICATION NAME] level is still below normal at 17.3. We increased her 2CalHN (nutritional supplement) to 3 ounces q.i.d. (four-times-daily) with MedPass. She is on ProSource, Magic Cup, and she has an air mattress to try to aid prevention of skin breakdown and healing of the areas that do breakdown."" A physician progress notes [REDACTED]. integrity at that time. Similar physician progress notes [REDACTED]. -- A review of nursing notes, recorded immediately before and after the heel protectors were discontinued on 02/10/11, did not reveal evidence that staff recognized the resident's lower extremity contractures resulted in her right heel constantly pressing against her buttocks. The following entries were noted with respect to the resident's heels: - On 02/06/11 at 2:00 p.m. - ""... Skin warm, dry, & intact. (Symbol for 'no') new area noted to skin. ..."" - On 02/20/11 at 2:25 p.m. - ""... Skin warm & dry, intact. Skin prep cont (continued) to heels. ..."" - On 03/06/11 at 10:15 a.m. - ""... Skin warm, dry & intact, skin prep to (B) (both) heels. ..."" - On 03/13/11 at 3:00 p.m. - ""... Remains on low air low mattress /c (with) (+) (positive) functioning & no bottoming out due to high risk for breakdown. Skin currently intact /c no pressure areas noted. ..."" - On 03/20/11 (7-3 shift) - ""... Skin assessment reveals (symbol for 'no') new skin issues."" - On 03/27/11 (7-3 shift) - ""... skin intact, (symbol for 'no') skin issues ..."" - On 04/03/11 at 2:00 p.m. - ""Resident's skin assessment completed. Right heel /c SDTI 1cm x 2 cm observed. Skin prep orders received and applied. ..."" - On 04/04/011 at 10:30 a.m. - ""(R) (right) heel /c SDTI ..."" -- Review of the resident's physician orders [REDACTED]. - On 04/03/11 at 2:00 p.m. - ""Skin prep to right heel every shift for two weeks then re-eval. Suspected deep tissue injury."" - On 04/04/11 at 1430 (2:30 p.m.) - ""Order clarification: Skin prep to both heels every shift. SDTI / [MEDICATION NAME] treatment."" - On 04/05/11 at 5:00 p.m. - [MEDICATION NAME] level d/t (due to) Stage I wound."" - On 04/06/11 at 1515 (3:15 p.m.) - ""... Order clarification - [MEDICATION NAME] level of 4-6-11 for SDTI."" No orders were received to address the underlying cause of the pressure sore until 04/19/11, when the following orders were received: - On 04/19/11 at 11:55 a.m. - ""PT eval & treat."" - On 04/19/11 at 11:55 a.m. - ""PT services 3 x 1 wk x 4 wks for LE stretching / ROM & positioning devices to decrease pressure & improve LE positioning while in bed."" -- b) Resident #41 Observation of Resident #41 revealed multiple joint contractures, with a Posey hand roll in use for contractures of the left hand. Review of the resident's current recapitulation of physician's orders [REDACTED]."" Review of Resident #41's care plan revealed the presence of left hand contractures, but the care plan was not revised to address the use of the Posey hand roll. During interview with the director of nursing on 04/21/11 at 11:30 p.m., she agreed the resident's care plan did not mention using a Posey roll or other splinting device for the contractures of the left hand, noting that in the past this resident refused them, but in recent times she had not been resistive to its application. .",2014-01-01
11502,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2011-04-26,323,D,,,NEGO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of facility incident / accident reports, observation, and staff interview, the facility failed, for one (1) of forty (40) Stage II sample residents, to care plan and/or implement measures to promote safety related to falls. Resident #21 was admitted to the facility on [DATE], after having been hospitalized for [REDACTED]. Interventions to promote safety related to falls were not addressed in her care plan until two (2) months after her admission, when the physician ordered a bed alarm on 12/28/10. Additional interventions (to include placing the resident's bed in a low position) were not added to the resident's care plan until the resident sustained [REDACTED]. When observed on 04/26/11, Resident #21 was observed to be asleep in her bed, but her bed was not in the low position as care planned. Resident identifier: #21. Facility census: 77. Findings include: a) Resident #21 When reviewed on 04/25/11, the medical record for Resident #21 revealed an admission date of [DATE]. According to a discharge summary report (dated 10/26/10) from the hospital where she was last admitted , this [AGE] year old female had fallen from bed in her home and sustained ""multiple bilateral lower extremity fractures"". The resident's individual interim plan of care, dated as completed on 10/27/10, was reviewed with respect to falls. The document stated the resident had the problem of falls due to a past history of falls. There were, however, no goals or approaches listed on the document to address this problem in an effort to prevent further falls. A physician's orders [REDACTED]. A falls investigation / root cause analysis form for this resident was noted to have been completed on 02/20/11. This document, and the information attached to it, stated the resident complained of hip pain when being re-positioned in the restorative room on the morning of 02/20/11, stating she fell out of bed the previous night and ""yelled for help"" and was assisted back to bed. Although the facility's investigation could provide no staff with knowledge of this incident, the resident received an x-ray to her right hip, which was negative for ""acute fractures"". An additional falls investigation / root cause analysis form for this resident was noted to have been completed on 03/31/11. This document, and the information attached to it, stated, ""I found resident sitting on floor between beds, she was yelling out, her alarm was on & working"". The document made no mention of the resident having been in a low bed at the time of the fall. An update to the resident's care plan was instituted on 03/31/11, stating the resident had an actual fall. Interventions at that time included: mat on floor; extensive assist with transfers; low bed; and start ""falling star"" program. The director of nursing (DON - Employee #63) was interviewed at 2:45 p.m. on 04/25/11. Following review of the resident's medical record and the above mentioned documents, the DON confirmed that no interventions to address falls were implemented at the time of admission (even though she had been hospitalized prior to her admission to the nursing home because of injuries she sustained as a result of a fall at home). Interventions were not implemented until after the resident had possibly fallen from the bed on 02/20/11 and after she had definitely fallen from the bed on 03/31/11. The resident was observed to be in bed asleep at 10:30 a.m. on 04/26/11. The bed was not in the low position. This observation was confirmed by a second surveyor at that time.",2014-01-01
11503,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2011-04-26,285,D,,,NEGO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for one (1) of forty (40) Stage II sample residents, to assure a reassessment was completed for a resident who was approved for nursing facility placement for less than three (3) months and remained in residence after six (6) months. Resident identifier: Resident #21. Facility census: 77. Findings include: a) Resident #21 When reviewed on 04/25/11, the medical record for Resident #21 revealed an admission date of [DATE]. Documentation found on page 5 of 6 of form PAS2000 for this resident disclosed, in Section #38 titled ""Physician Recommendation"", a nursing facility stay of less than three (3) months had been determined necessary for this resident. The resident had been at the facility for nearly six (6) months at that time. The facility's social worker (Employee #27), when interviewed on 04/25/11 at 1:15 p.m. following a review of the resident's record, confirmed the resident had not undergone reassessment, and the form PAS2000 had not been resubmitted following the initially approved three (3) month period. .",2014-01-01
11504,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2010-09-23,311,E,,,5AUJ11,". Based on record review and staff interview, the facility failed to provide daily restorative nursing services for residents designated to receives those services. Record review revealed specific written plans to meet specific goals for residents in the restorative nursing program. However, restorative aides were, at times, pulled to work the floor in the capacity of a nursing assistant due to staffing shortages, leaving the restorative nursing services undone. During interviews with certified nursing assistants (CNAs) conducted on 09/22/10, seven (7) of eight (8) CNAs interviewed reported they do not follow the restorative nursing plan; rather, they perform range of motion to restorative residents the same as they do to all dependent residents during the performance of activities of daily living. Resident identifiers: #10, #12, #49, #56, #57, #59, #61, #65, #70, #73, #77 #81, and #82. Facility census: 101. Findings include: a) Resident #10 Review of the Restorative Nursing Program (RNP) Flow Sheet, found in the restorative book for September 2010, revealed he was to ""perform active assist range of motion (ROM), bilat (bilateral) upper ext (extremities) all joints 3 sets of 20 (twenty) reps (repetitions) daily."" Restorative staff documented having provided this service on only nine (9) of the first twenty (20) days in September (9/2, 9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - b) Resident #12 Review of the RNP Flow Sheet for September 2010 revealed Resident #12 was to receive ""Active ROM (range of motion) ex (exercise) 2 sets 15 reps (repetitions) in seated position (heel / toe raises, seated marches, knee extension / flexion, hip abduction / adduction) daily"". Restorative staff documented having provided this service on only nine (9) of the first twenty (20) days in September (9/7, 9/8, 9/9, 9/10, 9/12, 9/13/, 9/14, 9/15, 9/16). Resident #12 was also to ""Ambulate /c (with) rolling walker - contact guard of 1 assist to daily tolerance / distance."" Restorative staff documented having provided this service on only six (6) of the first 20 (twenty) days in September (9/7, 9/8, 9/9, 9/10, 9/15/ 9/16). - c) Resident #49 Review of the RNP Flow Sheet for September 2010 revealed Resident #49 was to receive ""active assist ROM 3 sets 15 reps each (seated marches, knee ext while seated, hip abduction / adduction)"" and ""Ambulate /c rolling walker - min (minimum) assist of 1 (symbol for increase) to 50 ft or more as tolerated."" Restorative staff documented having provided this service on only four (4) of the first twenty (20) days of September, with four (4) refusals. Dates documented for both plans were 9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16. - d) Resident #56 Review of the RNP Flow Sheet for September 2010 revealed Resident #56 was to receive: ""Bilat (bilateral) lower ext (extremity) - active ROM 2 sets x 15 reps ... (seated marches, hip abduction / adduction, knee extension / flexion, heel / toe raises - dorsal / plantar flexion)."" Restorative staff documented having provided this service on only seven (7) of the first twenty (20) days of September (9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). Also, review of the RNP Flow Sheet for this time period revealed she was to: ""Ambulate /c rolling walker (10 - 30 ft) - verbal cue to keep walker @ correct distance in front of her."" Restorative staff documented having provided this service on only three (3) of the first twenty (20) days of September, with three (3) refusals (9/4, 9/7, 9/8, 9/14, 9/15, 9/16). Also, review of the RNP Flow Sheet for this time period revealed she was to have: ""Active Assist ROM (R) (right) upper ext (extremity) - 3 sets 15 reps... Active ROM (L) (left) upper ext - 3 sets 15 reps."" Restorative staff documented having provided this service on only seven (7) of the first 20 (twenty) days of September (9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - e) Resident #57 Review of the RNP Flow Sheet for September 2010 revealed Resident #57 was to receive: ""Active ROM - 3 sets 15 reps... passive ROM LUE (left upper extremity) and (L) hand - 3 sets 15 reps... wash & dry (L) hand - remove splint q (every) day - report any skin issues to nurse."" Restorative staff documented having provided this service on only eight (8) of the first twenty (20) days of September (9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - f) Resident #59 Review of the RNP Flow Sheet for September 2010 revealed Resident #59 was to maintain bilateral upper extremity strength and ""use 7 lb therapy bar during course of ADL (activity of daily living) - 3 sets - 20 reps or to tolerance."" This treatment was to have begun on 09/21/10. During an interview with Employee #54 on 09/22/10 at 11:30 a.m., she said it was not begun on 09/21/10, as staff did not know where the therapy bar was kept in the physical therapy department. - g) Resident #61 Review of the RNP Flow Sheet for September 2010 revealed Resident #61 was to: ""Ambulate up to 300 ft /c rolling walker - contact guard assist (may continue after resting) for (symbol for increased) ambulation if desired."" Restorative staff documented having provided this service on only eight (8) of the first twenty (20) days of September (9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). Also, she was to have: ""Bilat (bilateral) lower ext (extremity) 2 sets 15 reps AROM (active range of motion)... 2 lb ankle weight (seated marches, knee extension / flexion, hip abduction / adduction, dorsal / plantar circles... heel / toe raises."" Restorative staff documented having provided this service on only seven (7) of the first twenty (20) days of September on (9/4, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - h) Resident #65 Review of the RNP Flow Sheet for September 2010 revealed Resident #65 was to: ""Ambulate 400 ft + (plus) /c supv (supervision) - no assistive device."" Restorative staff documented having provided this service on eleven (11) of the first twenty (20) days of September (9/1, 9/2, 9/4, 9/7, 9/8, 9/9, 9/10, 9/12, 9/14, 9/15, 9/16). Also, she was to have: ""AROM bilat lower ext - cues may be necessary (heel / toe raises, knee extension / flexion, hip abduction / adduction) 2 sets - 15 reps."" Restorative staff documented having provided this service on only eleven (11) of the first twenty (20) days of September (9/1, 9/3, 9/4, 9/7, 9/8, 9/9, 9/10, 9/12, 9/14, 9/15, 916). She was also to receive: ""Active ROM bilateral upper ext 3 sets - 20 reps... verbal cues /c ADL's (activities of daily living) - dressing / grooming / toileting."" Restorative staff documented having provided this service on only nine (9) of the first twenty (20) days of September (9/4, 9/7, 9/8, 9/9, 9/10, 9/12, 9/14, 9/15, 9/16). - i) Resident #70 Review of the RNP Flow Sheet for September 2010 revealed Resident #70 was to have: ""Left upper ext all planes active ROM 3 sets - 20 reps."" Restorative staff documented having provided this service on only eight (8) of the first twenty (20) days of September (9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16), with one (1) refusal. - j) Resident #73 Review of the RNP Flow Sheet for September 2010 revealed Resident #73 was to: ""Ambulate /c rolling walker - CGA (contact guard assist) 300+ ft ... Active ROM BLE ex (bilateral lower extremity exercise) - heel / toe raises, seated marches, knee extension, hip abduction / adduction... Active ROM ex (exercise) - bilat upper ext all planes 3 sets - 30 reps."" Restorative staff documented having provided these service, which included two (2) days when the resident was out of the facility, on only nine (9) of the first twenty (20) days of September (9/1, 9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - k) Resident #77 Review of the RNP Flow Sheet for September 2010 revealed Resident #77 was to have"" ""Active ROM ex (L) upper ext 3 sets - 15 reps use 2 lb wgt (weight) if possible... Active assist ROM (R) upper ext 3 sets - 15 reps... Bilat lower ext active ROM 3 sets - 15 reps (ankle pumps, knee extension, hip flexion, seated marches, hip abduction / adduction."" Restorative staff documented having provided these service on only seven (7) of the first twenty (20) days of September (9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - l) Resident #81 Review of the RNP Flow Sheet for September 2010 revealed Resident #81 was to: ""Ambulate /c rolling walker 150 ft min (minimum) contact guard assist... verbal cues to (symbol for increase) step length / stay inside walker."" Restorative staff documented having provided this service on only four (4) of the first twenty (20) days of September (9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16), with four (4) refusals. - m) Resident #82 Review of the RNP Flow Sheet for September 2010 revealed Resident #82 was to have: ""Active ROM - bilat lower ext - 3 sets 15 reps (seated marches, hip abduction / adduction, seated knee ext (extension)."" Restorative staff documented having provided this service on only nine (9) of the first twenty (20) days of September (9/2, 9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). Also, she was to: ""Ambulate /c rolling walker - contact guard assist of one to tolerance."" Restorative staff documented having provided this service on only eight (8) of the first twenty (20) days in September (9/4, 9/7, 9/8, 9/9, 9/10, 9/14, 9/15, 9/16). - n) During an interview with a restorative aide (Employee #58) on 09/20/10 at 5:45 p.m., she stated that restorative services were provided for each resident seven (7) days per week. She said there was one (1) restorative aide who worked from 10:00 a.m. to 6:00 p.m., and there were two (2) restorative aides who worked the 7:00 a.m. to 3:00 p.m. (7-3) shift. She said two (2) restorative aides were pulled to work the floor today, leaving the other restorative aide to obtain weights on thirty (30) residents and then work 1:1 with another resident. For this reason, the restorative aides did not perform restorative nursing services today to all residents who to receive services - other than restorative dining in the dining room for five (5) residents; a nurse would be at the restorative table for the evening meal. She said she did not perform range of motion exercises or assist with ambulating any restorative residents in the hall today. - o) During an interview with a nurse (Employee #43) on 09/21/10 at 2:00 p.m., regarding all the ""blanks"" in the Restorative Book where nothing was documented to show restorative services were done on those days, she said a new program went into effect the beginning of September whereby copies of the RNP Flow Sheets for residents and their specific treatments are placed in the NA's (nursing assistant's) ADL (Activities of Daily Living) book for NAs to sign on days they provide restorative nursing services. - p) During an interview with another nurse (Employee #101) on 09/21/10 at 2:10 p.m., she said the nursing assistants do the restorative care on the 7-3 shift if the restorative aides get pulled to work the floor. - q) During interviews on 09/21/10 at 2:20 p.m. with nursing assistants who provided care today or yesterday to the following residents (Employees #31, #94, and #59), the aides were asked what restorative nursing services they provided and answers were as follows: - For Resident #31 - ""walked him to the bathroom and to the chair"", ""got range of motion to the upper and lower extremities today for a total of 10 minutes - restorative did it."" - For Resident #63 - ""was taken to the bathroom and transferred back and forth to the commode"" - For Resident #6 - ""transferred from the bed to the chair, moved arms and legs about 10 minutes"" - For Resident #56 - ""took her to the bathroom about ten times"" - For Resident #23 - ""helped during bathing"" - For Resident #10 - ""walked to the bathroom twice"" - For Resident #17 - ""worked arms and legs when changed"" - For Resident #82 - ""walked her to the bathroom and back"" - For Resident #49 - ""walked to the bathroom twice"" - For Resident #70 - ""walked to the bathroom to the hallway and to the chair"" - For Resident #81 - ""walked him to the bathroom"" - For Resident #66 - ""walked to the bathroom"" - For Resident #92 - ""had range of motion to the upper extremities today for 10 minutes - restorative did it."" - r) During an interview with Employee #43 on 09/21/10 at 3:15 p.m., she said the process for the CNAs to provide restorative care when the restorative aides were not available just started the first of September. She stated that the CNAs, nurses, and physical therapy have all met with inservices given, and all the CNAs should know how to do restorative nursing services, but perhaps not all know how to do it correctly yet. When asked, she said she believed the restorative aide positions were here to stay, but she was certain. However, they want to empower the CNAs to be able to do restorative nursing care as part of their daily duties. - s) During an interview with the director of nursing (DON) on 09/21/10 at approximately 5:30 p.m. regarding what nursing assistants said they were providing to restorative residents on days the restorative aides were absent or pulled to the floor to work as CNAs, she said it was probably just the ""verbiage"" they were unfamiliar, with as they have all received inservice education on restorative care. - t) During interviews with eight (8) nursing assistants (Employees #31, #27, #54, #55, #59, #94, #112, and #108) on 09/22/10 from 10:00 a.m. to 11:45 a.m. seven (7) of the eight (8) replied, when asked, that they do ADLs with residents who are in the restorative program and do range of motion to their joints during the process of performing routine care, just as they do for all dependent residents. They were in agreement that, when they sign on the Restorative Nursing Flow Sheet, they are signifying that range of motion was completed during their shift plus getting them up in a chair and/or walking them to the toilet if they are able. They were in agreement that the restorative staff perform lengthy ambulation per the restorative plan, although they (the CNAs) will walk a resident in the hall if he/she asks; and it is the restorative staff that does specific exercises (such as seated marches, etc., and exercises with repetitions and sets), not the CNAs. One (1) of the eight (8) CNAs said she does the exercises and repetitions according to the Restorative Nursing Plan, but she said she was not sure what hip abduction / adduction entails. Also, she was unable to describe what PROM and AROM entails. - u) During an interview with the staff development nurse (Employee #104) on 09/22/10 at 12:15 p.m., she reported the facility conducted a CNA class that ended in July with twelve (12) graduates, and five (5) of them are currently working at the facility. Also, the current CNA class graduates on 09/23/10, with six (6) students in that class and they test on 10/09/10. She said the next class begins on 09/29/10 with ten (10) students. She spoke of her desire for the facility to be able to hire and retain more CNAs. - v) Prior to exit for the day on 09/22/10 at approximately 4:00 p.m., the DON was informed of the continued concern regarding whether residents in the restorative nursing program were getting services as specified in the restorative nursing program flow sheet on days the restorative aides were absent or were pulled to work the floor as CNAs (instead of restorative aides). No further evidence was produced prior to exit on 09/23/10.",2014-01-01
11505,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2009-05-29,152,D,,,E5O711,"Based on medical record review, and staff interview, the facility failed to assure the right to make medical decisions for one (1) of ten (10) sampled residents was exercised in accordance with State law (the West Virginia Health Care Decisions Act). The facility allowed a health care surrogate (HCS) to transfer decision-making authority to a different family member when the HCS was unavailable. Resident identifier: #4. Facility census: 29. Findings include: a) Resident #4 Review of Resident #4's medical record found the treating physician determined the resident lacked capacity to understand and make informed medical decisions on 04/17/09. The physician appointed Family Member #1 to act as the resident's HCS. Further review found a handwritten, notarized document which appeared to be authored by Family Member #1, transferring the health care decision-making authority to Family Member #2 in the event Family Member #1 could not be reached. On 05/28/09 at 1:00 p.m., the document was shown to two (2) facility nurses (Employees #24 and #27). Each was asked what they would do if Family Member #1 could not be reached to make a health care decision. Both stated that, because the document was notarized, they would contact Family Member #2 to make health care decisions. Review of section 16-30-8 (a) of the West Virginia Health Care Decisions Act found the following language, ""When a person is or becomes incapacitated, the attending physician or the advanced nurse practitioner with the assistance of other health care providers as necessary, shall select, in writing, a surrogate."" The facility allowed a HCS to transfer medical decision-making authority to another individual in violation of the West Virginia Health Care Decisions Act. Only the attending physician or advanced nurse practitioner may select a surrogate decision-maker. .",2014-01-01
11506,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2009-05-29,225,E,,,E5O711,"Based on review of personnel records and other facility documents and staff interview, the facility failed to assure comprehensive screening was completed for three (3) of five (5) newly hired employees. Additionally, the facility failed to report an allegation of abuse involving one (1) resident to the State survey and certification agency and other officials in accordance with State Law. These deficient practices had the potential of affecting more than an isolated number of residents currently residing in the facility. Employee identifiers: #7, #14, and #76. Resident identifier: #2. Facility census: 29. Findings include: a) Employees #7, #14, and #76 1. Review of personnel records, on the afternoon of 05/29/0,9 found the facility did not obtain references from two (2) known previous employers prior to hiring Employee #7. 2. Further review found the facility did not obtain a criminal background check for the state of Ohio, when this state was listed as a previous residence of Employee #14. 3. It was also found the facility failed to access the Nurse Aide Abuse Registry to assure Employee #76 did not have findings of abuse or neglect registered with this state agency. Employee #32, who was assisting with review of the personnel records, was unable to provide evidence to show the required pre-employment screening for Employees #7, #14, and #76 was obtained by the facility. b) Resident #2 Review of facility records found, on 05/04/09, the daughter of Resident #2 sent an e-mail to the social services director alleging Employee #3 was ""... smacking Mom's behind for wanting up at night to use the potty chair ... The woman may be teasing with Mom, but Mom is taking it as a punishment. Mom should not have to receive this treatment."" Further review could find no evidence this allegation of abuse was reported to the State survey and certification agency or adult protective services in accordance with State law. An interview with Employee #32, on the afternoon of 05/29/09, confirmed this allegation had not been reported as required. .",2014-01-01
11507,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2009-05-29,329,E,,,E5O711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and pharmacist recommendation, the facility failed to assure the drug regimens of three (3) of ten (10) residents remained free from unnecessary drugs, used in excessive dose, for an excessive duration, and/or without indications for use. Resident identifiers: #1, #14, and #10. Facility census: 29. Findings include: a) Resident #1 1. Review of the medical record found Resident #1 was currently receiving [MEDICATION NAME] 50 mg twice-a-day (BID) and [MEDICATION NAME] 100 mg BID. Further review found a 03/17/09 recommendation from the consultant pharmacist informing the physician these two (2) drugs were considered duplication of therapy. The pharmacist asked the physician to consider stopping one (1) of the drugs. The physician did not acknowledge the pharmacist's recommendation. 2. Further review found the resident received [MEDICATION NAME] 1 mg at bedtime. A pharmacy recommendation, dated 01/20/08 (more than fifteen (15) months earlier) notified the physician that a gradual dose reduction needed to be attempted every six (6) months. The physician did not acknowledge the pharmacist's recommendation, and the resident remained on [MEDICATION NAME] 1 mg at bedtime. b) Resident #14 Review of the medical record found a physician's orders [REDACTED]. The resident was [MEDICATION NAME] mg BID for ten (10) days. On 04/13/09, an order for [REDACTED]. The medical record contained the urine culture report, marked as having been received at 5:01 p.m. on 04/13/09. The report documented no growth of bacteria after forty-eight (48) hours. There was no documentation to reflect the treating physician was notified of this laboratory report. The nurses administered [MEDICATION NAME] 500 mg for a total of eight (8) days beginning at 2:00 p.m. on 04/13/09, and continued [MEDICATION NAME] mg for seven (7) days after receiving the laboratory report. c) Resident #10 The physician [MEDICATION NAME] mg BID for ten (10) days for treatment of [REDACTED]. On 03/24/09 at 9:31 a.m., the facility received a laboratory report which determined the bacteria present in the resident's urine (Escherichia Coli) were resistant to Cipro. A handwritten note indicated the report was faxed to the physician at 10:00 a.m. on 03/24/09. The resident continued to [MEDICATION NAME] the evening shift on 03/24/09 and the day and evening shifts on 03/25/09, after being notified by the laboratory the bacteria present in the resident's urine were resistant to Cipro. The facility did not receive orders for an appropriate antibiotic until 5:00 a.m. on 03/26/09. .",2014-01-01
11508,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2009-05-29,428,D,,,E5O711,"Based on medical record review and review of a pharmacy report of irregularities for two (2) of ten (10) sampled residents, the facility failed to assure the pharmacist's recommendation for a gradual dose reduction of Ativan was acted upon by the physician. Resident identifiers: #1 and #14. Facility census: 29. Findings include: a) Resident #1 Review of the medical record found Resident #1 was currently receiving Lyrica 50 mg twice-a-day (BID) and Neurontin 100 mg BID. Further review found a 03/17/09 recommendation from the consultant pharmacist informing the physician these two (2) drugs were considered duplication of therapy. The pharmacist asked the physician to consider stopping one (1) of the drugs. The physician did not acknowledge or act upon the pharmacist's recommendation. b) Resident #14 Review of the medical record found a pharmacy's consult to the physician dated 04/22/09. The pharmacist notified the physician the resident was ordered MS (morphine sulfate) 30 mg BID on 04/06/09, in addition to a current order for Oxycodone 10/650 every six (6) hours as needed (PRN) for pain. The pharmacist noted the order for Oxycodone did not contain parameters for nursing as to when the PRN Oxycodone should be administered. The physician failed to acknowledge or act upon the pharmacy recommendation. .",2014-01-01
11509,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2009-05-29,502,D,,,E5O711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure laboratory services were obtained for one (1) of ten (10) sampled residents. Resident identifier: #10. Facility census: 29. Findings include: a) Resident #10 Review of the medical record found the resident was administered antibiotics for treatment of [REDACTED]. The treating physician ordered a repeat urinalysis with urine culture on 04/12/09. Review of the medical record found no evidence the laboratory test was obtained. An interview with a member of the nursing staff (Employee #27), on 05/28/09 at 9:50 a.m., confirmed the facility had not obtained the ordered test. .",2014-01-01
11510,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2009-05-29,505,D,,,E5O711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure the physician was promptly notified of laboratory findings for two (2) of ten (10) sampled residents. Resident identifiers: #14 and #10. Facility census: 29. Findings include: a) Resident #14 Review of the medical record found a physician's orders [REDACTED]. The resident was [MEDICATION NAME] mg BID for ten (10) days on 04/10/09. On 04/13/09, an order for [REDACTED]. The medical record contained the urine culture report, marked as having been received at 5:01 p.m. on 04/13/09. The report documented no growth of bacteria after forty-eight (48) hours. There was no documentation to reflect the treating physician was notified of this laboratory report. The nurses continued to administer both [MEDICATION NAME] 500 mg [MEDICATION NAME] mg after receiving the laboratory culture which indicated no bacteria growth after forty-eight (48) hours. The medical record contained no evidence the facility notified the physician of the laboratory results. An interview with a member of nursing staff (Employee #27), on the morning of 05/29/09, confirmed the facility could provide no evidence the physician was notified. c) Resident #10 The physician [MEDICATION NAME] mg BID for ten (10) days for treatment of [REDACTED]. On 03/24/09 at 9:31 a.m., the facility received a laboratory report which determined the bacteria present in the resident's urine (Escherichia Coli) were resistant to Cipro. A handwritten note indicated the report was faxed to the physician at 10:00 a.m. on 03/24/09. The resident continued to [MEDICATION NAME] the evening shift on 03/24/09 and the day and evening shifts on 03/25/09, after being notified by the laboratory the bacteria present in the resident's urine were resistant to Cipro. The facility did not receive orders for an appropriate antibiotic until 5:00 a.m. on 03/26/09. The facility could provide no evidence the physician was notified in a timely manner of the laboratory results to assure Resident #10 received the appropriate antibiotic to treat her UTI in a timely manner. .",2014-01-01
11511,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2009-05-29,309,D,,,E5O711,"Based on medical record review and staff interview, the facility failed to assure appropriate follow-up nursing assessment was provided to one (1) of ten (10) sampled residents. Nursing staff documented Resident #10 experienced bright red bleeding from the perineal area with no evidence of continued monitoring or assessment. Resident identifier: #10. Facility census: 29. Findings include: a) Resident #10 Review of the medical record found a 04/20/09 nursing note which documented the resident was having a small amount of bright red bleeding from the perineal area during her bed bath at 10:30 a.m. The nursing note documented that, upon assessment, the bleeding appeared to be coming from the urinary meatus. The medical record contained no further information concerning the bleeding from the resident's perineal area. The next nursing note was not written until the weekly note on 04/24/09. An interview with a member of the nursing staff, on the morning of 05/29/09, could provide no evidence the resident received further assessment or monitoring of the area. .",2014-01-01
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
11518,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-09-10,225,D,,,9G3Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on resident interview, review of facility documents, and staff interview, the facility failed to ensure two (2) of two (2) allegations of neglect / abuse were reported immediately to the State survey and certification agency and other officials in accordance with State law, and failed to thoroughly investigate the allegations of neglect / abuse. It was further determined that, due to the failure of the facility to report and investigate allegations appropriately, the facility failed to take appropriate corrective actions. The facility failed to immediately report one (1) allegation of neglect, when a staff member failed to assure Resident #81's bed was placed in the low position with landing strips (utilized to pad the floor) placed beside the resident's bed prior to leaving the resident unattended, in accordance with the resident's physician orders. The resident fell from her bed and sustained a [MEDICAL CONDITION] which required surgical repair. The facility did not report this allegation until three (3) days after the incident. The facility failed to report, investigate, or take appropriate corrective actions when Residents #117 and #52 made complaints to facility staff concerning Employee #5 on 08/26/10, and requested that she no longer provide care for them. Resident identifiers: #81, #117, and #52. Facility census: 118. Findings include: a) Resident #81 Review of facility documents found that, on 08/22/10 at 6:30 p.m., Resident #81 was found on the floor of her room. The resident's bed was left in a high position with no ordered landing strips placed on the floor beside her bed. The resident was subsequently hospitalized with a [MEDICAL CONDITION] which required surgical repair. Further review of facility documents found the graduate nursing assistant (Employee #136), who had been assigned to provide care for the resident on the day of the fall, claimed to be unaware that the resident was to have landing strips beside her bed. Review of the medical record found a current physician's orders [REDACTED]. The facility's records showed this allegation of neglect was not reported to State agencies until 08/25/10, three (3) days after the incident. An interview with the licensed social worker (LSW - Employee #73), on 09/08/10 at 4:45 p.m., confirmed the facility did not report the allegation of neglect immediately to adult protective services and the State survey and certification agency as required. - b) Residents #117 and #52 During random interviews conducted with alert and oriented residents on 09/09/10, Resident #117 stated, at 8:45 a.m., that approximately two (2) weeks ago, she woke up at 2:00 a.m. and asked a nursing assistant (Employee #5) to assist her in getting up. The resident stated Employee #5 refused to assist her and told her that she had to stay in the bed. The resident stated she asked the nursing assistant from the other hall (Employee #89) to help her get out of bed, and this aide assisted her. The resident further stated that, after being assisted up and going into the hallway, Employee #5 pointed her finger at her and told her it would be a long time before she could go back to bed. This allegation was reported to the director of nursing (DON - Employee #10) at 9:10 a.m. on 09/09/10. She denied having prior knowledge of this incident. Review of the resident council minutes for 08/26/10 found a communication from a member of the activities department (Employee #84) to the DON at 4:15 p.m., which stated, ""(Resident #117 and Resident #52) no longer want (Employee #5) to take care of them, they each have different issues regarding her care and I ask that u (you) please speak with them both."" An interview with Employee #84, at 12:50 p.m. on 09/10/10, confirmed the residents were complaining about Employee #5. She stated this was a nursing issue and she had reported it to both the DON and the unit manager. The DON, when asked at 10:10 a.m. on 09/09/10 about the 4:14 p.m. communication on 08/26/10, stated that, when she received, it she assigned it to her unit manager, and the issue has now been reported. Review of the 09/09/10 reported allegation of neglect related to Employee #5 found the facility both reported the allegation and completed the five-day follow-up on 09/09/10. The investigation merely consisted of the unit manager's late entry nursing note dated 09/07/10. The document contained no attempts to determine the date the incident happened, no attempts to obtain statements from the residents or staff members who were either involved in the incident or were potential witnessed the incident. Review of the medical record found the minimum data set (MDS), with an assessment reference date (ARD) of 06/30/10, assessed Resident #117 as being independent in cognitive skills for daily decision making with no deficits with long or short term memory, no indicators of [MEDICAL CONDITION], no mood problems, no behavioral problems, and being able to understand and make herself understood. The facility assessed the resident as requiring the extensive physical assistance of one (1) staff member with transfers. Review of the resident's current care plan, provided by the facility on 09/09/10, found under the problem of activities of daily living (ADL): ""Resident is dependent with transfers with slideboard."" The facility did not report or investigate potential allegations of abuse / neglect when informed of Residents #117 and #52's concerns on 08/26/10. Additionally, the nursing assistant (Employee #5) who was the subject of resident complaints continued to be assigned to care for Residents #117 and #52 when no attempts had been made that ensure it was safe to do so. .",2014-01-01
11519,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-09-10,224,G,,,9G3Y11,"**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 ensure that goods and services were provided to prevent physical harm to one (1) of eight (8) sampled residents. Facility staff failed to assure that physician-ordered landing strips (utilized to pad / cushion the floor) were placed beside Resident #81's bed and failed to assure her bed was in a low position when left unattended on 08/22/10. Resident #81 fell from the bed and sustained a [MEDICAL CONDITION] requiring surgical repair. The graduate nursing assistant (Employee #136) responsible for the resident's care on 08/22/10 denied having knowledge of the requirement to place landing strips beside the resident's bed. The facility failed to put into place a system to orient new employees and temporary agency staff to the planned / ordered interventions to be provided to each resident. Resident identifier: #81. Facility census: 118. Findings include: a) Resident #81 Review of facility documents found that, on 08/22/10 at 6:30 p.m., Resident #81 fell from her bed to the floor. Facility staff documented the resident's bed was in a high to knee-high position with no physician-ordered landing strips present to cushion the floor beside the resident's bed. The resident sustained [REDACTED]. Review of the medical record found an active physician's orders [REDACTED]. Review of the minimum data set (MDS) assessment, with an assessment reference date (ARD) of 07/05/10, found the resident was assessed as being severely cognitively impaired with impaired long and short term memory, and she required the extensive physical assistance of one (1) staff member for bed mobility, transfers, dressing eating, toilet use, and personal hygiene. The assessor also noted resident had sustained a fall in the thirty (30) days prior to the ARD. - Further review of facility information, concerning Resident #81's fall from bed on 08/22/10, found Employee #136 stated she had no knowledge that the resident was to have landing strips placed beside her bed. Review of the one-on-one education, conducted by the facility on 08/30/10, found the nurse informed the staff member: ""...there are Kardex (sic) on every station. Please look at your resident's Kardex at beginning of shift to ensure you are aware of interventions in place to prevent falls and to give appropriate care."" There was a lack of evidence to reflect the facility put procedures in place to inform other new staff and temporary agency staff of the care information located in the Kardex prior to providing care to assigned residents. - An interview was conducted with a nursing assistant employed by an outside temporary staffing agency (Employee #140) at 7:40 a.m. on 09/09/10. She was asked to show this surveyor where she would locate care instructions to assure that residents received appropriate care and services, such as, landing strips, bed height, splints, etc. Employee #140 walked behind the nursing station and retrieved the activity of daily living (ADL) book. When the documents were reviewed in the ADL book, it was noted that it merely contained a record of the residents' bowel movements, intake, bathing, etc. The book contained no instructions to staff concerning landing strips, bed height, splints, or other necessary care and services to be provided. When asked what a Kardex was, the aide stated that she did not know. A subsequent interview with the charge nurse on the unit (Employee #6) revealed she had not oriented the agency nurse aide as to where to locate the Kardex to access care information for residents. .",2014-01-01
11520,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-09-10,514,D,,,9G3Y11,"**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 maintain the medical record of one (1) of eight (8) sampled residents in accordance with accepted professional standards and practices. Resident #81 sustained a fall resulting in a [MEDICAL CONDITION], but her medical record contained no progress note entries addressing the fall or the resident's subsequent hospitalization . Resident identifier: #81. Facility census: 118. Findings include: a) Resident #81 Review of facility documents found Resident #81 sustained a fall from her bed on 08/22/10 and suffered a [MEDICAL CONDITION] requiring surgical repair. Review of the medical record found no nursing progress note or other documentation of the resident's fall and subsequent transfer to the hospital. An interview with the director of nursing (DON - Employee #10), on 09/10/10 at 4:00 p.m., confirmed the medical record did not contain progress notes or any other documentation of the resident's fall and subsequent transfer to the hospital on [DATE].",2014-01-01
11521,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-09-10,242,D,,,9G3Y11,". Based on review of resident council minutes and staff interview, the facility failed to assure one (1) random resident with a sample of eight (8) residents was afforded the right to choose bathing schedules consistent with aspects of his life in the facility that were significant to him. Resident identifier: #25. Facility census: 118. Findings include: a) Resident #25 Review of resident council minutes for 06/23/10 found Resident #25 requested that he be provided showers three (3) times a week. The response from the facility stated, ""Not staffed for 3 showers per week."" Under discussion of old business for the 07/26/10 resident council meeting, the minutes documented, ""We are not staffed to give residents 3 showers a week."" An interview with the administrator, on 09/09/10 at 9:10 a.m., revealed the wishes of the resident should have been honored. .",2014-01-01
11522,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-09-10,241,D,,,9G3Y11,". Based on observation, the facility failed to assure one (1) of eight sampled residents (Resident #96) was provided care in a manner that maintained her dignity while being transported through the hallway to the shower. Resident identifier: #96. Facility census: 118. Finding include: a) Resident #96 Random observations of the facility, on 09/08/10 at 4:10 p.m., found a staff member transporting Resident #96 through the hallway on a shower chair. The resident was seated on a commode-seat type shower chair. The staff member had placed a sheet around the top of the resident but failed to assure the resident's bottom was covered. The resident's unclothed buttocks were visible beneath the chair as the staff member pushed her down the hallway. This practice was brought to the attention of the unit manager (Employee #53), who obtained a sheet from the clean linen cart in the hallway and assured the resident was adequately covered. .",2014-01-01
11523,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2010-09-10,364,E,,,9G3Y11,". Based on observation, resident interview, and staff interview, the facility failed to assure the evening meal served on 09/08/10 was prepared in a manner that assured the food was palatable and attractive. This deficient practice affected more than an isolated number of residents receiving an oral diet. Facility census: 118. Findings include: a) Random observation of the evening meal, on 09/08/10, noted residents were served two (2) mounds of a grey-white gelatinous substance containing green flecks. It was noted that none of the residents eating in their rooms consumed the substance. When asked how the evening meal tasted, a resident (who wished to remain anonymous) described the taste as ""Yucky"". Another resident stated that it smelled like dog food. An interview with the dietary manager (Employee #16) was conducted at 6:25 p.m. on 09/08/10. When inquiry was made as to what the two (2) mounds of green-flecked substance served to residents were, she stated, ""Turkey Tetrazzini."" She stated the broccoli was overcooked due to the cook having to take her test and not getting back in time. She agreed the meal did not smell or look appetizing. .",2014-01-01
11524,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-09-03,314,G,,,GVP311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of hospital records, staff interview, family interview, and interview with a hospital social worker, the facility failed, for one (1) of ten (10) sampled residents, to ensure a resident who entered the facility with pressure sores received necessary treatment and services to promote healing and prevent infection. Resident #115 entered the facility on 07/14/10 with a Stage III pressure sore on her coccyx and Stage I pressure sores on her right hip and left heel. From 07/28/10 to 08/04/10, the wound on the resident's coccyx significantly increased in size and developed necrotic tissue and slough which prevented staging of the wound; the staff did not notify either the resident's responsible party or attending physician of the worsening of this wound. Upon the resident arrival at the hospital (after being transferred at the insistence of the resident's responsible party on 08/07/10), the wound was ""large and foul-smelling"" and the odor was ""overpowering""; prior to her transfer, the facility's documentation of this wound made no mention of any odor or signs / symptoms of infection. The resident was subsequently treated with intravenous antibiotics and the wound received surgical debridement. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10 following a hospital stay. Prior to this hospitalization , she had been living at the home of her caregiver and medical power of attorney representative (MPOA). According to the hospital history and physical examination was brought to the ER (emergency room ) following (sic) history of generalized weakness, lethargy, not eating or drinking, oliguric (low urine output) with dark foul-smelling urine. In theER on workup, patient was noticed to be dehydrated. Patient was also noticed to have urinary tract infection. Patient was advised (sic) hospitalization for further workup and management of urosepsis and dehydration. ..."" According to a Transfer Summary Report hemodynamically stable"" and received [MEDICATION NAME] mg every twelve (12) hours to treat the UTI, and her discharge medications [MEDICATION NAME] twice daily for five (5) more days. Her list of final [DIAGNOSES REDACTED]. - 2. Review of Resident #115's admission orders [REDACTED]. Also present on her chart was a physician orders [REDACTED]. In Section B, the MPOA indicated that, if the resident has a pulse and/or is breathing, staff was to provide limited addition interventions, to include the use of medical treatment, IV fluids and cardiac monitoring as indicated; the resident's MPOA did not select ""comfort measures"". In Section D, the MPOA specifically indicated the resident was not to receive a feeding tube; while the MPOA did not indicate a preference with respect to the IV fluids, there was no specific prohibition against the administration of IV fluids. - 3. The nursing admission evaluation, dated 07/14/10, identified the resident was admitted with a Stage II pressure sore on the coccyx area measuring 5 cm x 4 cm x 0.2 cm, a Stage I pressure sore on the right hip measuring 2 cm x 2 cm, and a Stage I pressure sore on the left heel measuring 5 cm x 6 cm. On 07/14/10, the physician ordered the following treatment to the Stage III pressure sore on the coccyx: ""Stage III coccyx: Cleanse q3d (every three days) /c (with NSS (normal sterile saline). Apply [MEDICATION NAME] Aq. Cover /c [MEDICATION NAME] dsg (dressing)."" On 07/15/10, the order was changed to: ""Cleanse area /c NSS. Apply [MEDICATION NAME] (white). Cover /c [MEDICATION NAME]. Change dressing Q3D (every three days) & PRN (as needed)."" A review of the resident's comprehensive care plan, with an initiated date of 07/15/10, revealed the following problem statement: ""Stage I on right hip, left heel and stage (sic) III on coccyx related to recent hospitalization secondary to refusing to eat, drink, diabetes, mobility, contractures, impaired mobility (sic), incontinence."" The goal associated with this problem statement was: ""Skin will heal within the limits of the disease process."" Interventions intended to assist the resident in achieving this goal included: "" ... Evaluate and record wound status per facility guidelines until healed. ... Monitor for and report any evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etc. Notify family / responsible party of skin condition. ..."" - 4. A late entry in the skin progress notes, dated 07/15/10 (for 07/14/10), stated, ""Res (resident) admitted on [DATE] /c (with) diagnosis (sic) of UTI, [MEDICAL CONDITION], dementia,[MEDICAL CONDITIONS], TIA ([MEDICAL CONDITION]), contractures of upper & lower extremities. She had a Braden (scale) of 9 on admit (sic) very high risk for skin breakdown. Also not eating / drinking at hospital. She was admitted /c a Stage I on Right hip 2 x 2 red area, not open, PUSH = 6. Stage III on coccyx - 5 x 4 x 0.2 20% slough /c 80% granulation, no odor, no drainage, no swelling, no c/o (complaints of) pain /c tx (treatment). PUSH score = 12, also has a Stage I on left heel 5 x 6 , PUSH score = 10. Tx order. ... Enc (encourage) to eat & drink. ..."" A skin progress note, dated 07/21/10, stated, ""Wound rounds completed. DCD (director of care delivery) & wound nurse on rounds. (R) (right) hip 1 x 0.2 PUSH = 3 Stage I - coccyx 0.8 x 3.0 x 0.2 D (depth) PUSH = 8 Stage III - (LE) (left) heel 4 x 6 PUSH = 9 Stage I. Coccyx - 75% slough / 25% granulation, 0 (no) odor, 0 drainage, 0 swelling, 0 s/s (signs / symptoms) infection - tolerated tx well. ..."" A skin progress note, dated 07/29/10, stated, ""Wound rounds completed. Late entry (for 07/28/10). DCD ' s, DON (director of nursing), wound nurse, dietary, therapy present. (R) hip - 0.8 x 0.5 Stage I PUSH = 2, (L) heel - 3.0 x 5.0 Stage I PUSH = 9, coccyx - 2.8 x 0.7 x 0.3 Stage II PUSH = 7, 10% slough 90% granulation, 0 odor, 0 drainage, 0 s/s inf (infection) 0 s/s pain. ... Cont /c ordered tx."" A skin progress note, dated 08/04/10, stated, ""Wound rounds completed. DON, DCD ' s, wound nurse & therapy present. (R) hip 1.4 x 1.0 Stage = I PUSH = 5. (L) HEEL 2.0 x 3.0 Stage = I PUSH = 7. Coccyx 7.0 x 7.0 x 0.8 unstageable PUSH = 14 50% necrotic tissue, 25% slough, 25% granulation. 0 odor, 0 drainage, 0 s/s inf. 0 s/s pain. ... Cont /c ordered tx."" From 07/28/10 to 08/04/10, the pressure sore on Resident #115's coccyx increased in size and was no longer able to be visualized for staging due to the presence of necrotic tissue, although the wound care nurse documented there was no odor, drainage, or signs / symptoms of infection. The Stage I pressure sores or the resident's right hip and left heel did not open or change during this time. - 5. A review of the nursing notes, from 07/15/10 until 08/07/10, did not contain any assessment of the resident's pressure sores or documentation to reflect identification of any odor or other signs / symptoms of infection in the pressure sore on the resident's coccyx. - 6. On 08/07/10, the facility transferred Resident #115 to the hospital at the request of the resident's MPOA due to a change in the resident's mental status. - 7. According to the hospital history and physical examination ... (Resident #115) was brought to the emergency room with (sic) chief complaint of progressively worsening mental changes with generalized weakness and lethargy. Also patient has stopped eating and drinking for the last four days or more. ... Patient was advised (sic) hospitalization [MEDICAL CONDITION]; possible source is urinary tract infection and necrotic decubitus ulcer with severe dehydration. ... Patient was recently in (name of hospital) in July 2010 for similar urinary tract infection and dehydration, patient was treated, improved and was admitted to the nursing home following her last hospitalization . ..."" Under ""Clinical Assessment"" was noted: ""1.[MEDICAL CONDITION] secondary to urinary tract infection. 2. Necrotic sacral decubitus ulcer. 3. Severe dehydration. ..."" Under ""Plan"" was noted: ""Is to admit the patient, we will give her IV antibiotics and IV fluids. ..."" A review of the hospital's discharge summary, dated 08/19/10, found: ""(Resident #115) is an eighty-five year old Caucasian female, a nursing home resident who was hosptalized on [DATE] following history of unresponsiveness associated with generalized weakness, lethargy. On admission, patient was in septic shock. Patient was severely dehydrated ... Patient was hypotensive. Patient was started on IV fluids and was hospitalized for [REDACTED]. ... Clinical Assessment: 1. Infected decubitus ulcer. 2. Urinary tract infection - resolved. 3. [MEDICAL CONDITION]. ... Hospital Course: Patient was given normal saline, IV fluid challenge, followed by 150 cc per hour of IV fluids. ..."" A hospital follow-up note, dated 08/26/10, stated: "" This patient had a large decubit that was debrided and getting wound VAC (vacuum-assisted closure) treatment. The final hospital [DIAGNOSES REDACTED]. E-coli urosepsis. (Escherichia coli are bacteria found in feces.) 2. Infected necrotic sacral decubitus ulcer with staph infection. 3. Septic ulcer disease with GI (gastrointestinal) bleed and [MEDICAL CONDITION]. 4. Acute or [MEDICAL CONDITION]. ..."" - 8. An interview with a registered nurse (RN) supervisor (Employee #70), on 09/03/10 at 10:00 a.m., revealed the MPOA wanted Resident #115 to be sent to the hospital on [DATE]. Employee #70 stated, ""I offered to call the physician and obtain blood work to determine what was wrong with the resident, and the MPOA stated she wanted the resident sent to the hospital immediately. I called the physician and sent the resident to the hospital."" - 9. An interview with the wound care nurse, a registered nurse (RN - Employee #61), on 09/02/10 at 1:35 p.m., revealed, when the pressure sore on Resident #115's coccyx was assessed to have increased in size on 08/04/10 and was not able to be visualized for staging due to the presence of necrotic tissue, she did not call the physician. She further stated she was new to the position and relied on some of the other nursing staff to tell her what she needed to do concerning the pressure sores. She also stated that, now, if a resident's pressure sore changed as Resident #115's did, she would call the physician immediately and schedule the resident with the wound clinic. She stated she works during the week and, after she leaves the facility each day, the floor nurses are responsible for the treatments. The floor nurses are also responsible for the treatments on the weekends. - 10. An interview with the social worker at the hospital, on 09/03/10 at 9:00 a.m., revealed that, when the resident was brought to the hospital on [DATE], the hospital social worker went into the emergency room . She stated, ""The odor from the pressure sore was overpowering. I could not stand the smell. The emergency room nurses took pictures of the pressure sore on the resident's coccyx. It was large and foul smelling."" She further stated, ""I did the POST form on her last admission to the hospital in July 2010, and the MPOA did not want a feeding tube inserted but wanted antibiotics and IV fluids if needed. There was never any mention by the MPOA of not wanting IV fluids."" - 11. In a telephone interview on 08/30/10 at 8:45 p.m., Resident #115's MPOA revealed that, although she did not a feeding tube inserted, she did want to resident to receive antibiotics and IV fluids if necessary. - 12. The resident was admitted to the nursing home on 07/14/10, with a Stage III pressure sore on the coccyx. On 08/04/10, the pressure sore became larger in size and was no longer able to be visualized for staging due to the presence of necrotic tissue; neither the resident's MPOA nor the attending physician was notified of the deterioration in the status of this pressure sore. (See citation at F157.) On 08/07/10, the resident's MPOA asked that the resident be sent to the hospital. Upon arriving at the hospital, the pressure sore was found to be overwhelmingly malodorous and severely infected; however, the nursing notes in the resident's medical record at the nursing facility failed to identify the presence of any odor or signs / symptoms of infection prior to her transfer to the hospital. During the resident's second hospital stay, she required treatment with intravenous antibiotics related to the infected wound, and the wound subsequently received surgical debridement. .",2014-01-01
11525,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-09-03,327,G,,,GVP311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of hospital records, family interview, staff interview, and interview with the hospital social worker, the facility failed to provide, for one (1) of twelve (12) sampled residents, sufficient fluid intake to maintain proper hydration and health. Resident #115 was admitted to the nursing facility on 07/14/10, following a hospital stay during which she was treated for [REDACTED]. At the insistence of the resident's legal representative, the resident was transferred to the hospital on [DATE], where she was readmitted for urosepsis, an infected pressure sore, and severe dehydration. During her 24-day stay at the nursing facility, there was no evidence to reflect the nursing staff was routinely assessing / monitoring the resident for changes in hydration status / fluid balance, nor was there evidence to reflect the facility identified the need for administration of intravenous (IV) fluids to restore fluid balance, which was not prohibited by the resident's advance directives. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10 following a hospital stay. Prior to this hospitalization , she had been living at the home of her caregiver and medical power of attorney representative (MPOA). According to the hospital history and physical examination was brought to the ER (emergency room ) following (sic) history of generalized weakness, lethargy, not eating or drinking, oliguric (low urine output) with dark foul-smelling urine. In theER on workup, patient was noticed to be dehydrated. Patient was also noticed to have urinary tract infection. Patient was advised (sic) hospitalization for further workup and management of urosepsis and dehydration. ... "" According to a Transfer Summary Report hemodynamically stable"". Her list of final [DIAGNOSES REDACTED]. - 2. Review of Resident #115's admission orders [REDACTED]. Also present on her chart was a physician orders [REDACTED]. In Section B, the MPOA indicated that, if the resident has a pulse and/or is breathing, staff was to provide limited addition interventions, to include the use of medical treatment, IV fluids and cardiac monitoring as indicated; the resident's MPOA did not select ""comfort measures"". In Section D, the MPOA specifically indicated the resident was not to receive a feeding tube; while the MPOA did not indicate a preference with respect to the IV fluids, there was no specific prohibition against the administration of IV fluids. Upon admission, the physician ordered a ""no added salt"", pureed diet with ""level II fluids"" (honey-thick liquids). According to the resident's weights and vitals summary, her weight on admission (07/14/10) was 130.0# and her height was 63 inches. The diet order was changed to mechanical soft with pureed meats and nectar-thick liquids on 07/20/10. - 3. A nutrition risk assessment, completed by a registered dietitian (RD) on 07/21/10, identified Resident #115 as being at HIGH RISK (score of 8 or higher), with a total score of 16. The RD calculated the resident's total fluid needs as 1737 cc/day. The resident's risk factors included an average intake of 33% at meals during a 7-day observation period, dementia, an [MEDICATION NAME] level of 2.7 (residents with [MEDICATION NAME] of less than 3.0 are at high risk), and one (1) Stage III pressure sore on the coccyx (with Stage I pressure sores also noted on the right hip and left heel). The RD recommended the addition of ""Med Pass Supplement 2.0 60 ml 4 x day"" on 07/21/10 to provide additional calories and protein for wound healing. On 07/27/10, the physician ordered: ""Dietary consult - res(ident) not eating. ..."" On 07/28/10, the RD noted, ""Consult for res refusing to eat and wt (arrow pointing down) (sic) Res current wt 9-25-10 90.6 (pounds) /s (without) boots verified by re-wt. Boots weighed = 1# each. Res wt 7-23-10 98.2# wt 7-22-10 99.4# wt 7-18-10 127.4#. 130# 7-14-10. (Arrow pointing down) 39.4# / 30% / since adm (admission). Wt quest (questioned) on admit. Res has been refusing to eat per Nsg (nursing). Res current diet NAS mech soft, pureed meats & nectar liquids. Res avg (meal intake) 13% x 7 days (arrow pointing down) from 33% last review 7/21/10. Res currently receiving Med Pass 2.0 60ml 4 x day to supplement diet. Staff stated res consumed ice cream well 7-27-10 Rec (recommend) to add magic cup 1 x day at afternoon snack to provide 300cal/9g protein. Will contact POA to updated likes & dislikes. Will continue to encourage meal intakes."" On 07/29/10, the RD noted, ""Update (sic) res has started to consume meals better per Nsg (nursing). Nsg stated res will consume bite if presented /c (with) ice cream in between bites. ... D/T (due to) res intakes at meals are improving recommend to add Benical to lunch tray to help meet res needs. No further recommendations at this time. ..."" While the RD was addressing the resident's weight loss and nutritional needs on a periodic basis, there was no mention of whether the resident was meeting her daily fluid needs. - 4. Review of the resident's initial acute care plan (developed prior to completion of the comprehensive admission assessment), dated 07/15/10, found no mention of the need to monitor the resident's hydration status, in view of the fact that her final [DIAGNOSES REDACTED]. - 5. The resident's comprehensive admission assessment, with an assessment reference date of 07/21/10, revealed in Section B, the resident's cognitive skills for daily decision-making were severely impaired and she had problems with both short and long term memory. In Section G, she was totally dependent upon staff for bed mobility, transfers, dressing, eating, toilet use, and bathing. In Section I2, the assessor noted the resident had a UTI in the preceding thirty (30) days. None of the ""Indicators of Fluid Status"" (Items ""a"" through ""d"" in Section J1) was marked, indicating the resident did not have any problems with dehydration in the preceding seven (7) days; for example, the assessor did not mark ""Dehydrated; output exceeds input"" or ""Insufficient fluid; did NOT consume all / almost all liquids provided during last 3 days"". In Section V, the person completing the care planning decision indicated the interdisciplinary care team would proceed with addressing dehydration / fluid maintenance on the resident's comprehensive care plan. - 6. Review of the resident's comprehensive care plan, with an initiated date of 07/26/10, found no problem statements specifically addressing the resident's recent history of or risk for dehydration. A review of all problems, goals, and interventions identified on the 14-page care plan found no problem, goal, or intervention addressing the need to encourage adequate fluid intake or routinely assess / monitor the resident's hydration status / fluid balance. - 7. Nursing notes indicated, beginning on day of admission, that resident would refuse to eat by refusing to open her mouth. The resident would eat for the MPOA on visit to the facility. A nursing note, dated 07/25/10 at 10:30 a.m., revealed, ""... Staff able to get 2 bites of brfast (breakfast) & 60 ml of fluid into resident this am (morning)."" On 07/27/10 at 10:00 a.m., a nursing note revealed, ""... Res conts (continues) to ref (refuse) to eat / drink ... Res conts to allow food / liq (liquid) to run out of mouth."" - 8. On 08/07/10, the facility transferred Resident #115 to the hospital at the request of the resident's MPOA due to a change in the resident's mental status. - 9. According to the hospital history and physical examination ... (Resident #115) was brought to the emergency room with (sic) chief complaint of progressively worsening mental changes with generalized weakness and lethargy. Also patient has stopped eating and drinking for the last four days or more. ... Patient was advised (sic) hospitalization [MEDICAL CONDITION]; possible source is urinary tract infection and necrotic decubitus ulcer with severe dehydration. ... Patient was recently in (name of hospital) in July 2010 for similar urinary tract infection and dehydration, patient was treated, improved and was admitted to the nursing home following her last hospitalization . ..."" Under ""Clinical Assessment"" was noted: ""1.[MEDICAL CONDITION] secondary to urinary tract infection. 2. Necrotic sacral decubitus ulcer. 3. Severe dehydration. ..."" Under ""Plan"" was noted: ""Is to admit the patient, we will give her IV antibiotics and IV fluids. ..."" A review of the hospital's discharge summary, dated 08/19/10, found: ""(Resident #115) is an eighty-five year old Caucasian female, a nursing home resident who was hosptalized on [DATE] following history of unresponsiveness associated with generalized weakness, lethargy. On admission, patient was in septic shock. Patient was severely dehydrated ... Patient was hypotensive. Patient was started on IV fluids and was hospitalized for [REDACTED]. ... Clinical Assessment: 1. Infected decubitus ulcer. 2. Urinary tract infection - resolved. 3. [MEDICAL CONDITION]. ... Hospital Course: Patient was given normal saline, IV fluid challenge, followed by 150 cc per hour of IV fluids. ..."" The final hospital [DIAGNOSES REDACTED]. E-coli urosepsis. (Escherichia coli are bacteria found in feces.) 2. Infected necrotic sacral decubitus ulcer with staph infection. 3. Septic ulcer disease with GI (gastrointestinal) bleed and [MEDICAL CONDITION]. 4. Acute or [MEDICAL CONDITION]. ..."" - 10. An interview with a registered nurse (RN) supervisor (Employee #70), on 09/03/10 at 10:00 a.m., revealed the MPOA wanted Resident #115 to be sent to the hospital on [DATE]. Employee #70 stated, ""I offered to call the physician and obtain blood work to determine what was wrong with the resident, and the MPOA stated she wanted the resident sent to the hospital immediately. I called the physician and sent the resident to the hospital."" She further stated, ""I did not feel that the resident needed to go to the hospital, and she was not exhibiting any signs and symptoms of a urinary tract infection."" - 11. There was no evidence to reflect the facility had routinely assessed / monitor Resident #115's hydration status / fluid balance for signs / symptoms of dehydration with the knowledge that the resident was not eating, that her fluid intake was at a minimum, and that, prior to her admission to this facility, she had been treated for [REDACTED]. - 12. In a telephone interview on 08/30/10 at 8:45 p.m., Resident #115's MPOA revealed that, although she did not want a feeding tube inserted, she did want the resident to receive antibiotics and IV fluids if necessary. - 13. In an interview with the social worker at the hospital, on 09/03/10 at 9:00 a.m., she stated, ""I did the POST form on her last admission to the hospital in July 2010, and the MPOA did not want a feeding tube inserted but wanted antibiotics and IV fluids if needed. There was never any mention by the MPOA of not wanting IV fluids."" .",2014-01-01
11526,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-09-03,309,G,,,GVP311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of hospital records, family interview, staff interview, and interview with the hospital social worker, the facility failed to provide care and services necessary to attain or maintain the highest practical level of physical well-being for one (1) of twelve (12) sampled residents. Resident #115 was admitted to the nursing facility on 07/14/10, following a hospital stay during which she was treated for [REDACTED]. At the insistence of the resident's legal representative, the resident was transferred to the hospital on [DATE], where she was readmitted for urosepsis, severe dehydration, and an infected pressure sore. During her 24-day stay at the nursing facility, there was no evidence to reflect the nursing staff was routinely assessing / monitoring the resident for changes in her hydration status, quantity and quality of her urinary output, and/or presence of signs / symptoms of UTI. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10 following a hospital stay. Prior to this hospitalization , she had been living at the home of her caregiver and medical power of attorney representative (MPOA). According to the hospital history and physical examination was brought to the ER (emergency room ) following (sic) history of generalized weakness, lethargy, not eating or drinking, oliguric (low urine output) with dark foul-smelling urine. In theER on workup, patient was noticed to be dehydrated. Patient was also noticed to have urinary tract infection. Patient was advised (sic) hospitalization for further workup and management of urosepsis and dehydration. ..."" According to a Transfer Summary Report hemodynamically stable"" and received [MEDICATION NAME] mg every twelve (12) hours to treat the UTI, and her discharge medications [MEDICATION NAME] twice daily for five (5) more days. Her list of final [DIAGNOSES REDACTED]. - 2. Review of Resident #115's admission orders [REDACTED]. Her admitting orders [MEDICATION NAME] mg twice daily for five (5) days. Also present on her chart was a physician orders [REDACTED]. In Section B, the MPOA indicated that, if the resident has a pulse and/or is breathing, staff was to provide limited addition interventions, to include the use of medical treatment, IV fluids and cardiac monitoring as indicated; the resident's MPOA did not select ""comfort measures"". In Section D, the MPOA specifically indicated the resident was not to receive a feeding tube; while the MPOA did not indicate a preference with respect to the IV fluids, there was no specific prohibition against the administration of IV fluids. - 3. Review of the resident's initial acute care plan (developed prior to completion of the comprehensive admission assessment), dated 07/15/10, found no mention of the resident receiving five (5) days [MEDICATION NAME] daily or of the need to monitor the resident's hydration status, quality or quantity of urinary output, or for the presence of signs / symptoms of a UTI, in view of the fact that her final [DIAGNOSES REDACTED]. - 4. The resident's comprehensive admission assessment, with an assessment reference date of 07/21/10, revealed in Section B, the resident's cognitive skills for daily decision-making were severely impaired and she had problems with both short and long term memory. In Section G, she was totally dependent upon staff for bed mobility, transfers, dressing, eating, toilet use, and bathing. In Section I2, the assessor noted the resident had a UTI in the preceding thirty (30) days. None of the ""Indicators of Fluid Status"" (Items ""a"" through ""d"" in Section J1) was marked, indicating the resident did not have any problems with dehydration in the preceding seven (7) days; for example, the assessor did not mark ""Dehydrated; output exceeds input"" or ""Insufficient fluid; did NOT consume all / almost all liquids provided during last 3 days"". In Section V, the person completing the care planning decision indicated the interdisciplinary care team would proceed with addressing dehydration / fluid maintenance on the resident's comprehensive care plan. - 5. Review of the resident's comprehensive care plan, with an initiated date of 07/26/10, found no problem statements specifically addressing the resident's recent history of or risk for dehydration, oliguria, or UTI. The care plan did contain a problem statement addressing incontinence as follows: ""Urinary incontinence and bowel incontinence related to impaired Mobility, Cognitive Deficit, Physical Limitations."" The goals associated with this problem statement were: ""Will be maintained in as clean and dry dignified state as possible within confines of urinary dysfunction"" and ""No acute infection"". The interventions intended to assist the resident in achieving these goals were: ""Monitor for and report any changes in amount, frequency, color or odor of urine and stool and continency (sic). record (sic) bms (sic) (bowel movements) qs (every shift). Check for incontinence frequently and provide incontinent (sic) care."" - 6. Review of nursing notes, since admission on 07/14/10 through 08/07/10, found no evidence of periodic assessment or monitoring of the resident's hydration status, quality or quantity of urinary output, or for the presence of signs / symptoms of a UTI. The nursing notes did, however, note the resident was refusing to open her mouth and was not eating and/or drinking. - 7. On 08/07/10, the facility transferred Resident #115 to the hospital at the request of the resident's MPOA due to a change in the resident's mental status. - 8. According to the hospital history and physical examination ... (Resident #115) was brought to the emergency room with (sic) chief complaint of progressively worsening mental changes with generalized weakness and lethargy. Also patient has stopped eating and drinking for the last four days or more. ... Patient was advised (sic) hospitalization [MEDICAL CONDITION]; possible source is urinary tract infection and necrotic decubitus ulcer with severe dehydration. ... Patient was recently in (name of hospital) in July 2010 for similar urinary tract infection and dehydration, patient was treated, improved and was admitted to the nursing home following her last hospitalization . ..."" Under ""Clinical Assessment"" was noted: ""1.[MEDICAL CONDITION] secondary to urinary tract infection. 2. Necrotic sacral decubitus ulcer. 3. Severe dehydration. ..."" Under ""Plan"" was noted: ""Is to admit the patient, we will give her IV antibiotics and IV fluids. ..."" A review of the hospital's discharge summary, dated 08/19/10, found: ""(Resident #115) is an eighty-five year old Caucasian female, a nursing home resident who was hosptalized on [DATE] following history of unresponsiveness associated with generalized weakness, lethargy. On admission, patient was in septic shock. Patient was severely dehydrated ... Patient was hypotensive. Patient was started on IV fluids and was hospitalized for [REDACTED]. ... Clinical Assessment: 1. Infected decubitus ulcer. 2. Urinary tract infection - resolved. 3. [MEDICAL CONDITION]. ... Hospital Course: Patient was given normal saline, IV fluid challenge, followed by 150 cc per hour of IV fluids. Patient was also given IV antibiotic, [MEDICATION NAME] 1 gram daily and [MEDICATION NAME] 250 mg IV daily. ..."" The final hospital [DIAGNOSES REDACTED]. E-coli urosepsis. (Escherichia coli are bacteria found in feces.) 2. Infected necrotic sacral decubitus ulcer with staph infection. 3. Septic ulcer disease with GI (gastrointestinal) bleed and [MEDICAL CONDITION]. 4. Acute on [MEDICAL CONDITION]. ..."" - 9. An interview with a registered nurse (RN) supervisor (Employee #70), on 09/03/10 at 10:00 a.m., revealed the MPOA wanted Resident #115 to be sent to the hospital on [DATE]. Employee #70 stated, ""I offered to call the physician and obtain blood work to determine what was wrong with the resident, and the MPOA stated she wanted the resident sent to the hospital immediately. I called the physician and sent the resident to the hospital."" She further stated, ""I did not feel that the resident needed to go to the hospital, and she was not exhibiting any signs and symptoms of a urinary tract infection."" - 10. In a telephone interview on 08/30/10 at 8:45 p.m., Resident #115's MPOA revealed that, although she did not want a feeding tube inserted, she did want the resident to receive antibiotics and IV fluids if necessary. - 11. There was no evidence to reflect the facility conducted periodic assessment or monitoring of the resident's hydration status, of the quality or quantity of the resident's urinary output, or for the presence of signs / symptoms of a UTI with the knowledge that the resident was not eating, that her fluid intake was at a minimum, and that, prior to her admission to this facility, she had been treated for [REDACTED]. .",2014-01-01
11527,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-09-03,157,D,,,GVP311,". Based on record review and staff interview, the facility failed, for one (1) of twelve (12) sampled residents, to notify the resident's medical power of attorney representative (MPOA) and attending physician when the status of the resident's pressure sore significantly declined. Resident identifier: #115. Facility census: 114. Findings include: a) Resident #115 A review of the facility's weekly skin report for Resident #115, dated 08/04/10, found: ""The coccyx measurement is not able to be staged."" The pressure sore was described as measuring 7 cm x 7 cm x less than 0.8 cm with eschar. This was a significant change from the previous week when, on 07/28/10, the pressure sore on the resident's coccyx measured 2.8 cm x 0.7 cm x 0.3 cm and no eschar was present. A review of nursing notes, on 08/04/10, did not find evidence to reflect either the physician or the resident's MPOA was notified of this significant decline in status of the resident's pressure sore. An interview with the wound care nurse (a registered nurse - Employee #61), on 09/02/10 at 1:35 p.m., revealed, when on 08/04/10 the resident's pressure sore was assessed to be larger and was not able to be staged due to the eschar, she did not call the physician or notify the MPOA. .",2014-01-01
11528,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-09-03,225,E,,,GVP311,". Based on record review and staff interviews, the facility did not ensure that four (4) of eight (8) resident concern forms reviewed, containing allegations of resident abuse / neglect involving nursing assistants, were reported to the State nurse aide registry. Resident identifiers: #115, #116, #117, and #20. Facility census: 114. Findings include: a) A review of the facility's complaint file revealed four (4) resident concern forms containing allegations of resident abuse / neglect which involved nursing assistants. These allegations of abuse / neglect were reported to the facility by family members and residents as follows: 1. A concern form, dated 07/20/10, stated the medical power of attorney representative (MPOA) of Resident #115 reported finding the resident lying wet with food on her clothes. 2. A concern form, dated 08/21/10, stated Resident #116 ""stated she wanted to use BSC (bedside commode) but was told by 11-7 (night shift staff) that she needed to use the bedpan - 'that it's our protocol'. When she used the bedpan, the bed got wet. Res (resident) states only the top sheet was changed & the fitted sheet was still wet. When she told the CNA (certified nursing assistant) the bottom sheet was still wet, res says CNA said 'It's not wet unless you peed again' then (symbol for 'checked') the sheet & told res is was dry. Later res says she was cold & asked for a blanket. States CNA took her temp (97.1) & was told she 'didn't need a blanket.' Res was upset enough to tell (name of nurse) that she was ready to sign out AMA (against medical advice) the next morning. ..."" 3. A concern form, dated 08/21/10, stated, ""... Res (Resident #117) said 'I'm not one to complain' then hesitated. When asked what the problem was, he said 'You know. Night shift.' I asked what happened. Res stated 'When I had my light on, they came in & said 'What do you want now.' Res inferred it was said in a (sic) unpleasant tone of voice. Res then said CNA turned off the light & left the room."" 4. A concern form, dated 07/15/10, stated, ""Resident (#20) upset this AM (morning) stated that NS (night shift) ref (refused) to assist to BSC. Resident stated that NS staff told her that they could not get her OOB (out of bed) to BSC D/T (due to) only 3 staff & she requires 2 ppl (people) to do. Resident state (sic) this is a dignity issue. 'Why can't they not stand & pivot?'"" - An interview with the assistant director of nursing (ADON - Employee #23), on 09/02/10 at 3:05 p.m., revealed she was in charge of reviewing the complaints and reporting allegations to the appropriate State agency(ies). She further stated the four (4) complaints with the allegations of abuse / neglect were investigated by her and were not submitted to the State agency. She stated she talked with the nursing assistants involved but did not submit the allegations to the State nurse aide registry. - In an interview on 09/02/10 at 4:30 p.m., Resident #20, who was alert and oriented with the capacity to understand and make her own health care decision, stated she had asked an aide to assist her to the bedside commode and the aide refused. The resident knew who the aide was, but would not tell the surveyor. The resident stated she had told the facility's investigating nurse the name of the aide. She further stated, ""This was a dignity issue."" .",2014-01-01
11529,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-09-03,155,D,,,GVP311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of hospital records, family interview, and interview with a hospital social worker, the facility failed, for one (1) of ten (10) sampled residents, to honor the advance directives formulated by this incapacitated resident's medical power of attorney representative (MPOA). Record review revealed nursing staff and the attending physician believed Resident #115 was to receive only ""comfort measures"", which was contrary to the advance directives executed by the resident's MPOA. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10, following a hospital stay during which she was treated for [REDACTED]. - 2. Review of Resident #115's medical record found a physician orders [REDACTED]. In Section B, the MPOA indicated that, if the resident has a pulse and/or is breathing, staff was to provide limited addition interventions, to include the use of medical treatment, IV fluids and cardiac monitoring as indicated. The resident's MPOA did not select ""comfort measures"", which was an option available in this section. In Section D, the MPOA specifically indicated the resident was not to receive a feeding tube; while the MPOA did not indicate a preference with respect to the IV fluids, there was no specific prohibition against the administration of IV fluids. - 3. At the insistence of the resident's legal representative, the resident was transferred to the hospital on [DATE], where she was readmitted for urosepsis, an infected pressure sore, and severe dehydration. During her 24-day stay at the nursing facility, there was no evidence to reflect the nursing staff was routinely assessing / monitoring the resident for changes in hydration status / fluid balance, nor was there evidence to reflect the facility identified the need for administration of intravenous (IV) fluids to restore fluid balance. - 4. According to the hospital history and physical examination ... (Resident #115) was brought to the emergency room with (sic) chief complaint of progressively worsening mental changes with generalized weakness and lethargy. Also patient has stopped eating and drinking for the last four days or more. ... Patient was advised (sic) hospitalization [MEDICAL CONDITION]; possible source is urinary tract infection and necrotic decubitus ulcer with severe dehydration. ... Patient was recently in (name of hospital) in July 2010 for similar urinary tract infection and dehydration, patient was treated, improved and was admitted to the nursing home following her last hospitalization . ..."" Under ""Clinical Assessment"" was noted: ""1.[MEDICAL CONDITION] secondary to urinary tract infection. 2. Necrotic sacral decubitus ulcer. 3. Severe dehydration. ..."" Under ""Plan"" was noted: ""Is to admit the patient, we will give her IV antibiotics and IV fluids. ..."" The final hospital [DIAGNOSES REDACTED]. E-coli urosepsis. (Escherichia coli are bacteria found in feces.) 2. Infected necrotic sacral decubitus ulcer with staph infection. 3. Septic ulcer disease with GI (gastrointestinal) bleed and [MEDICAL CONDITION]. 4. Acute or [MEDICAL CONDITION]. ..."" - 5. Review of the nursing notes revealed an entry, dated 07/18/10 at 3:50 p.m., stating, ""... (Resident) Resting in bed until lunch. POA (power of attorney) in. Upset that her instructions (sic) not followed. Wants resident up prior to BRK (breakfast). ... This nurse was under the impression that this resident was to stay in bed & that she was comfort measures. Many CNA's (certified nursing assistants) also were of similar belief. ..."" In a progress note dated 08/01/10, the physician stated, ""Pt's (patient's) PO (oral) intake poor but pt's POST form does not allow any tube feeding. ... Plan - continue comfort measures. ..."" - 6. In a telephone interview on 08/30/10 at 8:45 p.m., Resident #115's MPOA revealed that, although she did not a feeding tube inserted, she did want to resident to receive antibiotics and IV fluids if necessary. - 7. An interview with the social worker at the hospital, on 09/03/10 at 9:00 a.m. revealed that, when the resident was brought to the hospital on [DATE], the hospital social worker stated, ""I did the POST form on her last admission to the hospital in July 2010, and the MPOA did not want a feeding tube inserted but wanted antibiotics and IV fluids if needed. There was never any mention by the MPOA of not wanting IV fluids."" - 8. The facility failed to ensure all staff was aware of and honored this resident's advance directives. .",2014-01-01
11530,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-09-03,279,D,,,GVP311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, the facility failed to develop a comprehensive care plan for one (1) of twelve (12) sampled residents describing the services to address all medical and nursing needs that were known to the facility. Resident #115 was admitted to the facility following a hospital stay during which she was treated for [REDACTED]. No care plan was developed to address the need for ensuring the resident maintained adequate hydration status / fluid balance and did not acquire a repeat UTI. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10 following a hospital stay. Prior to this hospitalization , she had been living at the home of her caregiver and medical power of attorney representative (MPOA). According to the hospital history and physical examination was brought to the ER (emergency room ) following (sic) history of generalized weakness, lethargy, not eating or drinking, oliguric (low urine output) with dark foul-smelling urine. In theER on workup, patient was noticed to be dehydrated. Patient was also noticed to have urinary tract infection. Patient was advised (sic) hospitalization for further workup and management of urosepsis and dehydration. ..."" According to a Transfer Summary Report hemodynamically stable"" and received [MEDICATION NAME] mg every twelve (12) hours to treat the UTI, and her discharge medications [MEDICATION NAME] twice daily for five (5) more days. Her list of final [DIAGNOSES REDACTED]. - 2. Review of Resident #115's admission orders [REDACTED]. Her admitting orders [MEDICATION NAME] mg twice daily for five (5) days. - 3. Review of the resident's initial acute care plan (developed prior to completion of the comprehensive admission assessment), dated 07/15/10, found no mention of the resident receiving five (5) days [MEDICATION NAME] daily or of the need to monitor the resident's hydration status, quality or quantity of urinary output, or for the presence of signs / symptoms of a UTI, in view of the fact that her final [DIAGNOSES REDACTED]. - 6. Review of nursing notes, since admission on 07/14/10 through 08/07/10, found multiple entries reporting the resident was refusing to open her mouth and was not eating and/or drinking. - 4. The resident's comprehensive admission assessment, with an assessment reference date of 07/21/10, revealed in Section B, the resident's cognitive skills for daily decision-making were severely impaired and she had problems with both short and long term memory. In Section G, she was totally dependent upon staff for bed mobility, transfers, dressing, eating, toilet use, and bathing. In Section I2, the assessor noted the resident had a UTI in the preceding thirty (30) days. None of the ""Indicators of Fluid Status"" (Items ""a"" through ""d"" in Section J1) was marked, indicating the resident did not have any problems with dehydration in the preceding seven (7) days; for example, the assessor did not mark ""Dehydrated; output exceeds input"" or ""Insufficient fluid; did NOT consume all / almost all liquids provided during last 3 days"". In Section V, the person completing the care planning decision indicated the interdisciplinary care team would proceed with addressing dehydration / fluid maintenance on the resident's comprehensive care plan. - 5. Review of the resident's comprehensive care plan, with an initiated date of 07/26/10, found no problem statements specifically addressing the resident's recent history of or risk for dehydration, oliguria, or UTI. The care plan did contain a problem statement addressing incontinence as follows: ""Urinary incontinence and bowel incontinence related to impaired Mobility, Cognitive Deficit, Physical Limitations."" The goals associated with this problem statement were: ""Will be maintained in as clean and dry dignified state as possible within confines of urinary dysfunction"" and ""No acute infection"". The interventions intended to assist the resident in achieving these goals were: ""Monitor for and report any changes in amount, frequency, color or odor of urine and stool and continency (sic). record (sic) bms (sic) (bowel movements) qs (every shift). Check for incontinence frequently and provide incontinent (sic) care."" A review of all problems, goals, and interventions identified on the 14-page comprehensive care plan found no problem, goal, or intervention addressing the need to encourage adequate fluid intake or routinely assess / monitor the resident's hydration status / fluid balance. - 7. On 08/07/10, the facility transferred Resident #115 to the hospital at the request of the resident's MPOA due to a change in the resident's mental status. - 8. According to the hospital history and physical examination ... (Resident #115) was brought to the emergency room with (sic) chief complaint of progressively worsening mental changes with generalized weakness and lethargy. Also patient has stopped eating and drinking for the last four days or more. ... Patient was advised (sic) hospitalization [MEDICAL CONDITION]; possible source is urinary tract infection and necrotic decubitus ulcer with severe dehydration. ... Patient was recently in (name of hospital) in July 2010 for similar urinary tract infection and dehydration, patient was treated, improved and was admitted to the nursing home following her last hospitalization . ..."" Under ""Clinical Assessment"" was noted: ""1.[MEDICAL CONDITION] secondary to urinary tract infection. 2. Necrotic sacral decubitus ulcer. 3. Severe dehydration. ..."" Under ""Plan"" was noted: ""Is to admit the patient, we will give her IV antibiotics and IV fluids. ..."" .",2014-01-01
11531,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-11-03,280,D,,,GVP312,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to review and/or revise the comprehensive care plan when the health care status and care needs changed for three (3) of fifteen (15) sampled residents. Resident identifiers: #4, #7, and #11. Facility census: 113. Findings include: a) Resident #4 A review of the medical record revealed Resident #4 was an [AGE] year old female admitted on [DATE] with multiple diagnoses. She was re-hospitalized shortly after admission and readmitted to the facility on [DATE]. Her attending physician ordered ""Comfort Measures Only"" on 10/15/10, due to a decline in her health care status and the recent [DIAGNOSES REDACTED]. The nursing notes and the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]""just wanted to go to sleep"". A review of the resident's care plan revealed there were no goals set and no nursing interventions to address the ""End of Life Care"" needs of this resident. During an interview with one (1) of the assistant director of nurses (ADON - Employee #3) at 2:40 p.m. on 11/02/10, she acknowledged these needs should have been addressed when the ""Comfort Measures Only"" order was written on 10/15/10. At 3:20 p.m. on 11/02/10, Employee #3 also confirmed there was no care plan revision addressing the resident's ""End of Life Care"" needs. -- b) Resident #7 A review of the medical record revealed Resident #7 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was recently hospitalized and readmitted on [DATE]. On 10/22/10, a suprapubic catheter was placed to aid in the healing of a pressure ulcer on the coccyx, a skin tear of the rectum, and the chronic UTIs. A review of the clinical record, on 11/02/10, failed to find evidence of a revision of the comprehensive care plan to include goals and nursing interventions for the care of the suprapubic catheter. There was also no interim plan of care established. The nursing notes on 10/27/10 documented there was urine seepage into the resident's adult incontinence brief, indicating that additional care was needed by direct care staff. During an interview with the director of nursing (DON - Employee #2) and both ADONs (Employees #3 and #4) at 12:40 p.m. on 11/02/10, they acknowledged, after reviewing the resident's current care plan, that a revision to address the presence of the suprapubic catheter had not been done. At 1:00 p.m., the Employee #3 returned, after checking the care plan books and the computer, and verified that the care needs associated with the presence of Resident #7's suprapubic catheter were not addressed in either the comprehensive or interim care plan. -- c) Resident #11 A review of the medical record revealed Resident #11 was an [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Her current comprehensive care plan, which was initiated on 08/03/10 and revised on 08/12/10, stated she was ""At risk for injury r/t (related to) fall due to impaired balance / poor coordination, [MEDICAL CONDITION]."". The goals associated with this potential problem were to ""minimize"" falls and/or injuries. The nursing interventions to meet these goals were: ""Assess for fall risk and reassess as needed; Bed in low position""; and Provide assist to transfer and ambulate as needed."" The nursing notes and an incident report related the resident sustained [REDACTED]. She sustained a laceration and was transported to the emergency room for sutures and a brain scan. The resident assessment protocol (RAP), completed by the nurse (Employee #4) on 10/11/10 stated a care plan was to be ""initiated / revised"" to address this. However, review of her care plan found no evidence of any revisions to prevent future falls, and there were no interventions addressing the safe use of the wheelchair. During an interview with the DON and both ADONs at 12:40 p.m. on 11/02/10, Employee #4 verified she had stated in the RAP that the resident's care plan would be reviewed / revised. At 1:30 p.m., the Employee #3 presented a copy of the RAP and acknowledged there had been no changes to the care plan after the resident's fall with injury. .",2014-01-01
11532,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-11-03,514,D,,,GVP312,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure an accurate and complete medical record by failing to transcribe a physician's phone order into the correct locations on the medical record which resulted in confusion during the investigation of a potential medication error in the treatment of [REDACTED]. Resident identifier: #7. Facility census: 113. Findings include: a) Resident #7 A review of the medical record revealed Resident #7 was a [AGE] year old female who received [MEDICATION NAME] daily for control of a [MEDICAL CONDITION] disorder. A recent hospitalization resulted in new medication orders when she was readmitted to the facility. When readmitted on [DATE], the physician ordered: ""[MEDICATION NAME] (125 mg/5 ml) 7.5 ml TID (3 times daily) PO (by mouth) and [MEDICATION NAME] 5 ml Q HS (at bedtime) PO."" On 09/30/10, these orders were changed. All previous [MEDICATION NAME] orders were discontinued, and the physician ordered: ""[MEDICATION NAME] 7.5 ml @ 8:00 a.m.; 5 ml @ 12:00 p.m.; and 7.5 ml @ 4:00 p.m. PO."" On 10/21/10, the laboratory results showed a drop in the resident's serum [MEDICATION NAME] level, and when the physician was notified, documentation on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]""[MEDICATION NAME] (125 mg/5 ml) 5ml Q HS PO."" There was no evidence in the physician's orders [REDACTED]. During an interview with the nurse (Employee #7) at 2:30 p.m. on 11/02/10, she stated, after reviewing the record, that she was the nurse who had reported the laboratory values to the physician's office and received the new order, which she had placed on the MAR, but she had failed to transcribe the order onto the physician's orders [REDACTED].",2014-01-01
11533,"BRIER, THE",515144,601 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2010-09-28,441,D,,,QQ4P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to maintain an infection control program designed to prevent the spread of infection within the resident environment to the greatest extent possible. One (1) of four (4) sampled residents with an open portal of entry (an indwelling urinary catheter) was cohorted in a room with a resident with a wound that cultured positive for an infectious organism. Resident identifier: #27. Facility census: 89. Findings include: a) Resident #27 Medical record review for Resident #27, conducted on 09/27/10 and 09/28/10, revealed Resident #27, who was being treated by a urologist, had an indwelling Foley urinary catheter inserted from 07/26/10 through 07/30/10. On 07/26/10, the physician ordered: ""1. [MEDICATION NAME] plus 1 tablet po (by mouth) bid (twice a day) x 5 days dx (diagnosis) pain. 2. If pain continues may resume Tylenol #3 1 tablet po four times a day PRN (as needed). 3. Stop Keflex. 4. [MEDICATION NAME] mg 1 tablet po bid x 2 weeks. F/C (indwelling Foley urinary catheter) care q (every) shift until Friday 07/30/10."" Review of the resident's nursing notes revealed the following entries: - On 07/26/10 - ""F/C patent to leg ..."" - On 07/27/10 - ""F/C patent to leg drainage bag. Orange urine noted ..."" - On 07/28/10 - ""F/C patent to drainage on leg bag. Some leakage noticed but good flow ..."" - On 07/30/10 - ""Cath was removed yesterday R/T (related to) burning and leaking ..."" During this time, Resident #27 shared a room with Resident #90, who was in contact isolation from 07/21/10 through 08/26/10. - b) Resident #90 Medical record review for Resident #90 revealed lab results, dated 07/14/10, showing positive growth of Methicillin-resistant Staphylococcus aureus (MRSA) in wounds on his right foot. On 07/21/10, Resident #90 was placed in contact isolation due to this MRSA infection, for which he was treated with several courses of antibiotics. A follow-up wound culture, dated 08/03/10, found no growth of MRSA at that time, although the culture was positive for Morganella morganii. On 08/26/10, the physician ordered, ""Discontinue Isolation."" - c) In an interview at approximately 3:00 p.m. on 09/28/10, Employee #2 (the registered nurse who has responsibility for the infection control program at the facility) identified that Resident #27 should not have resided in the room with Resident #90 after the indwelling urinary catheter was inserted into Resident #27 (as this created an open portal for entry by infectious organisms). Employee #2 presented a copy of a reference she used in her facility for MRSA. The reference material came from the following Internet site: . The reference material stated the following: ""Contact precautions must be used when a resident is colonized or infected with MRSA in any site other than the nares .... Nasal colonization of a resident with MRSA does not warrant precautions other than standard precautions unless that resident is considered to be epidemiologically linked, either as a source or as a spread case, to an outbreak of MRSA in the facility. ""Contact precautions consist of the following components: ""Contact precautions must be used when a resident is colonized or infected with MRSA IN ANY SITE OTHER THAN THE NARES ... Contact precautions consist of the following components. ""1. Room placement and Activities ""- A resident who is colonized or infected with MRSA at any body site other than the nares should be placed according to the following scheme: ""-- Most Desirable: A private room or cohorting with another resident who is colonized / infected with MRSA. ""-- Less Desirable: A room with another resident who has intact skin and no 'tubes' (invasive feeding tubes, tracheotomy tubes, any type of intravascular line, any type of indwelling urinary drainage tube, or any other tube or device that breaks the skin or enters into a normal body orifice).""",2014-01-01
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
11537,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2010-09-16,204,D,,,WF8P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, record review, and staff interview, the facility failed to provide sufficient preparation at discharge of one (1) of six (6) sampled residents to ensure an orderly transfer from the facility, by failing to safeguard and return timely to the resident and/or responsible party important personal documents left in the facility's possession on admission which could not be produced at the time of the resident's discharge. Resident identifier: #96. Facility census: 94. Findings include: a) Resident #94 During an interview at 3:15 p.m. on 09/13/10, Resident #96's responsible party reported she had not yet received the resident's Medicare benefits card, social security card, or her driver's license, which she had given to staff at the time of the resident's admission to the facility on [DATE]. Resident #96 was discharged from the facility on 08/20/10. The responsible party stated these identification cards were necessary for obtaining health care services for the resident. Review of the resident's closed record revealed a copy of the resident's Medicare benefits card, confirming it had been presented to the facility. There was no mention in the record of the location of the original card. During an interview with the social worker (Employee #8) at 10:40 a.m. on 09/16/10, she acknowledged the cards had not been returned and, in fact, could not be located. She stated she had met with the resident's daughter shortly before her mother's discharge and returned jewelry that had been held for the resident in the facility's safe. At that time, the daughter asked her about the cards. Employee #8 had no knowledge of the cards and had assured the daughter she would locate them and have them returned. She stated this duty had been given to the admissions clerk, who reported she had them in her possession and volunteered to return them. A week ago, the social worker had been contacted again by the resident's daughter, who had again requested the cards. When asked, the admissions clerk told Employee #8 that she had attempted to return them, and the daughter would not come to her door. The social worker stated that, on 09/10/10, she had prepared a letter to be sent to the daughter by certified mail on 09/13/10, and she produced the letter requesting the daughter to contact the facility and arrange for the return of the cards. This letter was not sent because, when the social worker arrived at the facility on Monday 09/13/10, she discovered the admissions clerk had quit on Friday 09/10/10 and could not be contacted. A search of her office failed to produce the cards. In a subsequent interview, the administrator joined the social worker. The administrator stated he was unaware the cards had not been returned, and he reported he had no knowledge of their current location. He confirmed the facility's admissions clerk had quit unexpectedly on 09/10/10. He stated it was the facility's practice for the admissions clerk to obtain the cards during the admission process, but they should be copied and returned to the responsible party. He did not know why this was not done for Resident #96.",2014-01-01
11538,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2010-09-03,323,J,,,LWGO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of self-reported events, staff interview, review of quality assurance (QA) committee meeting minutes offered by the facility, medical record review, review of incident / accident reports, and review of the facility's policy and procedure room transfers, the facility failed to provide adequate supervision and/or assistive devices to ensure the safety of two (2) residents who shared a room with a third resident whom staff believed placed the roommates at risk for harm. Resident #26 shared a 3-bed room with Residents #38 and #77. Resident #26 was alert, oriented to person, place, and season, had short-term memory problems, and his cognitive skills for daily decision-making were assessed as being ""modified independence""; he was also independent with activities of daily living (ADLs). Resident #38 was alert with severely impaired cognitive skills for daily decision-making; he did not communicate with others and was totally dependent with ADLs. Resident #77 was alert, oriented, and independent with daily decision-making, required extensive assistance with bed mobility and transfers, did not ambulate, and was totally dependent on staff for locomotion. On the early morning of [DATE], staff responding to Resident #26's call light found Resident #38 on the floor positioned with his pads, bed linens, and positioning wedge placed on and under him as if he were still in bed; Resident #38 was not capable of having transferred out of bed himself. On the late night of [DATE], staff found Resident #38's legs had been repositioned in bed in a different position than one in which staff had put him during their previous rounds. The nurse directed staff to monitor all residents in this room every twenty (20) minutes, because Resident #38 was not physically able to move himself, Resident #77 was not physically able to independently transfer out of his own bed, and Resident #26 was behaving in a suspicious manner. During these monitoring rounds, in the early morning hours of [DATE], staff found Resident #38's legs again had been repositioned, and staff found a pillow had been placed over the face of Resident #77. In [DATE], Resident #26 had shared this same room with another resident (#87) who was also found by staff at that time to have a pillow placed over his face. In response to these findings, the facility met with Resident #26's guardian, who agreed to allow him to be evaluated at a psychiatric hospital. Prior to his transfer on [DATE], the facility stationed a staff member in the room at all times to monitor the residents for safety. Resident #26 returned to the facility on [DATE], to the same room shared with Residents #38 and #77. Although the aftercare plan from the psychiatric hospital included the recommendation that the nursing home ""observe / assess need for further treatment"", the facility failed to review / revise Resident #26's care plan to address this. Upon his return, no additional supervision and/or assistive devices were put into place to monitor Resident #26 (especially at night) and/or ensure the ongoing safety of Residents #38 and #77. This placed Residents #38 and #77 in immediate jeopardy. On [DATE] at 11:00 a.m., the administrator, medical director, director of nursing, social worker (Employee #52), and the clinical care coordinator (Employee #33) were notified of the finding of immediate jeopardy. At 11:40 a.m. on [DATE], the administrator provided an action plan, which was reviewed and accepted by the nurse surveyor at 11:45 a.m. The action plan included the following steps: Resident #26 was transferred to a private room on another floor, staff was instructed to observe and record Resident #26's behavior on an hourly basis, and Resident #26's care plan was revised to reflect these actions. On [DATE] at 1:30 p.m., the nurse surveyor verified that Resident #26 was relocated, and the immediate jeopardy was removed with no deficient practice remaining. Facility census: 87. Findings include: a) Residents #26, #38, and #77 1. Observation, during tour beginning at 9:30 a.m. on [DATE], found Residents #26, #38, and #77 sharing the same 3-bed room. - 2. On [DATE] at 10:25 a.m., review of events self-reported by the facility to the State survey and certification agency during the previous three (3) months revealed the following ""unusual occurrence"": ""On [DATE] at 2:30 a.m. the C.N.A. (certified nursing assistant) had entered the room to respond to Resident (#26) call light when Resident (#38) was found on floor beside his bed. Resident (#38) was found on floor still covered in blankets with pink pad under him and wedge cushion behind his back. ""... due to Resident (#38) need for total assistance with ADL's that (sic) this incident did not appear to be the result of the resident falling out of bed. There is concern that he may have had assistance from his roommate. ... Residents in room will be monitored by staff at more frequent intervals. ... ""Another incident occurred in this same room on the this same date of [DATE] where Resident (#77) was observed by nursing staff with a pillow over his face during the early a.m. (morning) interval checks. Resident (#77) did not know how the pillow got on his face. There were no apparent injuries to either resident."" According to a message confirmation report, this ""unusual occurrence"" was faxed to the State survey agency at 2:45 p.m. on [DATE]. - 3. Review of the medical records for Residents #38 and #77 found entries in the nursing notes relating the same information as stated in the unusual occurrence report mentioned above. - Review of Resident #38's most recent resident assessment, a Medicare 14-day assessment with an assessment reference date (ARD) of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He was alert with long and short term memory problems, he was not oriented to person, place, or season, he was unable to communicate with others, and he was totally dependent upon staff for all ADLs, including bed mobility and transferring. - Review of Resident #77's most recent resident assessment, a quarterly assessment with an ARD of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE]. He was alert and oriented and independent with his cognitive skills for daily decision-making, and he required extensive assistance with bed mobility and transfers, did not ambulate, and was totally dependent on staff for locomotion. His [DIAGNOSES REDACTED]. - Review of Resident #26's most recent resident assessment, a quarterly assessment with an ARD of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE]. Resident #26 was alert, oriented to person, place, and season, had short-term memory problems, and his cognitive skills for daily decision-making were assessed as being ""modified independence""; he was independent with ADLs. His [DIAGNOSES REDACTED]. - Review of nursing notes in Resident #26's record found no entry by the nurse on the night shift from [DATE] to [DATE]. An entry, recorded by the nurse during the night shift from [DATE] to [DATE] (at 2:00 a.m. on [DATE]), stated, ""Resident up most of the night walking around the room. Denies pain or discomfort."" - Review of Resident #26's Plan of Care Kardex for the month of [DATE] found several notes recorded by nursing assistants, starting on [DATE], regarding Resident #26's behavior towards his roommates. On [DATE] (no time or shift noted), a nursing assistant wrote: ""Res (resident) was standing behind the curtain between his bed and (Resident #38's) bed, ask (sic) him what he was doing & Resident stated he wasn't doing anything. CNA (initials of nursing assistant) ask (sic) him to go lay down in his bed or if he couldn't sleep to sit in his chair, that he just couldn't mess with his Room-mate (sic) (Resident #38) or Room-mates (sic) things. He said all right."" Another note on [DATE] (identified as being written on the 7:00 a.m. to 3:00 p.m. shift) stated, ""Res stands behind curtains when your (sic) trying to give care to roommate."" On [DATE], a nursing assistant wrote: ""Res standing behind the curtain when giving care to roommate"" Another entry (no date / time) stated, ""Resident got upset when taking roommate to Bathroom (sic)."" - On the reverse side of Resident #26's [DATE] ADL flow record, a nursing assistant wrote, on [DATE], ""Resident behind curtain looking and trying to see the patient when staff was giving care."" - Review of the physician's progress notes for Resident #26 found the following entries: - On [DATE]: ""I was called last night by (facility) to call (name of administrator), which I did. She related they had a concern about (Resident #26), that in the room he has 2 other roommates, (Resident #38) and (Resident #77). (Resident #38) was found in the floor twice reported by staff. (Resident #38) is not able to move himself. The staff became suspicious then they went over to see (Resident #77) and a pillow was on his head. When they asked (Resident #77) if he was ok (sic) he said yes (sic) and they asked him how the pillow got there (sic) and he related he did not know how. (Resident #26) had been up during the night. He had gone to the bathroom, (sic) in the morning it was reported to (name of administrator) that something suspicious was going on and they fear it would be (Resident #26). They discussed it with the daughter (of Resident #26) who was upset. They discussed there was (sic) odd behaviors that had gone on with he (sic) and (Resident #87 - previous roommate who is now deceased ) (sic) however they did not get along. I called to talk to the daughter and she was at (facility). She wanted me to come down and talk to her (sic) which I did, this was about 8pm. ... I told her we should have an evaluation by doctor in (name of psychiatric hospital). ..."" (Interview with the administrator, on the morning of [DATE], verified that Resident #38 was found on the floor only once, contrary to what was stated above, although his feet were found to have been moved towards the side of the bed on two (2) separate occasions - which the resident was not capable of doing himself.) - On [DATE]: ""We had a family conference today with the daughter, sister, (name of regional ombudsman), Director (sic) of nurses and myself. We discussed (Resident #26). My recommendation is that he got to (city name) to be evaluated. ... I did discuss with her (daughter / guardian of Resident #26) the night before that he and (Resident #87 - previous roommate no longer at the facility) had some disagreements ... At one time there was a pillow that was found beside (Resident #87) and a pillow was found over his face. ... She knows (Resident #38) was found in the floor. He can not (sic) move himself. Then (Resident #77) was found with a pillow over his head. ... The daughter understands we did not see (Resident #26) do this. We do not know what happened. ... I told her to be safe it was important for him to evaluated. ..."" - 4. A QA committee plan of correction, generated on [DATE] and provided for review to the surveyor by the facility's administrator at 8:00 a.m. on [DATE], revealed the incident involving Resident #38 occurred on the night shift that ran from [DATE] to [DATE], and the incident involving Resident #77 occurred on the night shift that ran from [DATE] to [DATE]; they did not occur within the same 8-hour shift on [DATE]. This [DATE] QA committee plan of correction stated: ""On Monday morning, [DATE], (name) DON (director of nursing) was notified by the nursing staff that there had been a concern with residents in room (Number of room shared by Residents #26, #38, and #77) on Sunday and in the early morning hours of Monday. At approximately 2:30 a.m. resident (#26) had rung his call bell. When the staff responded they observed resident (#38) lying in the floor. When they asked resident (#26) what he needed he said 'nothing'. Resident (#38) was lying in the floor with his under pads, covers and wedge cushion in place. On [DATE] at approximately 11:30 p.m. resident (#38) was observed with his feet over the right side of the bed and at 12:15 a.m. on [DATE] resident (#38) was again observed with his feet over the left side of the bed. Resident (#77) was observed at 12:30 a.m. with a pillow over his face. ... ""INVESTIGATION FINDINGS AND INTERVENTIONS TO CORRECT THE PROBLEM: ""- Resident (#38) is totally dependent upon staff for bed mobility, transfers, ADLS (activities of daily living) and feeding. ""- Call bell is in place for resident (#38) at all times; however, resident does not use call bell independently. ""- Resident (#38) is turned and repositioned q2hrs (every two hours) by staff. ""- Resident (#77) voices needs and wants to staff, rings call bell independently, requires extensive assist of one with bed mobility, transfers with two and dressing, personal hygiene and bathing with the assist of one. ""- Resident (#26) is independent with all ADLs, mobility, ambulates through out (sic) the facility independently, voices needs and wants to staff and rings call bell for assistance as needed. ""- Resident (#26) has documented behaviors related to past roommates. ..."" According to the administrator, due to Resident #26's past behaviors towards roommates and Resident #38's inability to move on his own and his position on the floor with covers and wedge in place, staff questioned whether Resident #26 was involved in removing Resident #38 from bed to floor and his moving feet over the sides of the bed. Staff also questioned whether Resident #26 placed the pillow over Resident #77's face. Checks of the room shared by these three (3) residents were made every twenty (20) minutes for the remainder of the night shift ending on the morning of [DATE]. Staff communicated with the responsible parties of all residents involved and made arrangements to transfer Resident #26 to a psychiatric hospital for evaluation. Until this transfer could be accomplished, the facility assigned a staff member to remain at all times in the room shared by these three (3) residents, since the responsible parties of the residents all refused to allow their family member to be relocated for safety. - 5. Resident #26's guardian agreed to allow him to be transferred to a psychiatric unit for evaluation. According to the nursing notes, the resident was transferred from the facility to the psychiatric hospital at about 2:30 p.m. on [DATE]. - 6. Resident #26 was readmitted to the facility on [DATE] and was placed back into the same room with his previous roommates, Residents #38 and #77. Review of the aftercare plan from the psychiatric hospital, dated [DATE], found the resident was initially admitted for agitation, aggression, and sexually inappropriate behavior. Under the heading ""Patient Treatment Goals / Progress"", staff at the psychiatric hospital wrote: ""Patient has not displayed any agitation or aggression since admission and had not had any sexually inappropriate behavior for several days."" Under the heading ""Diagnosis"" was written: ""Axis I: Dementia, AD (Alzheimer's disease) type /c (with) depressed mood and behavioral disturbance. Axis II: Schizoid Personality D/O (disorder). ... Axis IV: NH (nursing home) placement. ..."" Under the heading ""Discharge Recommendations / Plan"" was written: ""NH to observe and assess for further treatment."" An interview with the administrator, on [DATE] at 4:00 p.m., found Resident #26's guardian refused to allow the resident to be moved. She also indicated Residents #38's responsible party and Resident #77 (who had capacity) did not want to change rooms. - 7. In an interview on [DATE] at 8:30 a.m., the medical director acknowledged her awareness of the situation regarding Resident #26. She had questions about the ability to move a resident to another without the health care decision maker's consent. On [DATE] between 8:30 a.m. and 9:45 a.m., intermittent observations made with the medical director found all three (3) residents together in the same room with no specific measures in place to ensure the safety of the roommates. At 9:45 a.m. on [DATE], the facility's ""Resident Transfer"" policy (no date), was requested of and provided for review by the administrator. Review of the policy revealed the following: ""Policy: 1. Transfer of Residents Within the Manor: ... C. In the case of emergency the facility reserves the right to make a move but will notify the resident or their responsible party."" ""Procedure: Transfer of Patient: ... 8. Due to changes in patient's condition, we reserve the right to transfer the patient to the area where we can best meet his or her needs."" This information was shared with the medical director. - 8. One (1) of the facility's social workers, (Employee #52) was interviewed at 10:30 a.m. on [DATE]. She sat in on a meeting with Resident #26, his daughter / guardian, and his sister on [DATE]. The resident was sent to the psych unit to determine if he had tendencies to be physically aggressive towards other residents. - 9. Employee #19 (the LPN who completed the above-referenced incident reports for Residents #38 and #77) provided handwritten notes, as well as documentation of observations made by staff of Residents #26 and #38 every twenty (20) minutes from 1:00 a.m. to 6:20 a.m. on [DATE], to the director of nursing (DON) on [DATE]. The DON provided copies of this documentation for review to this nurse surveyor at 10:40 a.m. on [DATE]. The first note stated: ""On [DATE] at 2:30 AM (sic) The CNA's were responding to (Resident #26)'s call light. When they went into the room he said he didn't need anything and that's (sic) when they found (Resident #38) lying on the floor. On the (L) side of the bed on his back. He still had his pads underneath him & his blankets were wrapped around him and the wedge they place behind his back was tucked under his (L) side. Both bedrails were also up. Prior to him being in the floor (sic) (Resident #38) was positioned in bed on his (R) side /c (with) the wedge behind his back. I am letting you know about this b/c (because) I find his falling in the floor suspicious and don't see how he could have ended up in the floor like that on his own."" - The second note stated: ""Just for clarification - On ,[DATE] @ 2:30 AM (Resident #38) was in the floor on the (L) side of his bed in between the bed & the rocker chair. He was on his back /c pads underneath him & blankets wrapped around his legs & the wedge was underneath his (L) hand side. His bed rails were up & his bed was in (sic) low position. Prior to him being in the floor he was positioned on his (R) side /c wedge behind him on the left side of his back. ""On ,[DATE] @ 1130 PM when walking up the hall his feet were pulled to the (R) side of the bed and he was laying (sic) on his (R) side. ""At 12:15 AM - now [DATE] Resident was lying on (R) side and his feet were pulled to the (L) side of the bed. ""After that is when we found (Resident #77) with the pillow on his face. ""That's (sic) when I initiated the 20 minute check paper for the CNA to fill out."" (During an interview on [DATE] at 5:15 p.m., Employee #19 verified her statements.) - 10. The DON, when interviewed on [DATE] at 10:45 a.m., reported a resident service provider (RSP) was assigned to provide one-on-one supervision of Resident #26 from [DATE] at 2:30 p.m. through [DATE] at 2:30 p.m., when he went to the hospital. The DON reported became suspicious of Resident #26's behavior after she reviewed the 24-hour shift reports for [DATE] and [DATE], which indicated Resident #38 was found on the floor during the early morning hours on [DATE] (on the night shift starting on [DATE]) and was found two (2) times with his feet hanging off the bed during the night shift starting on [DATE]. Documentation on the 24-hour shift report for [DATE] stated, ""[DATE] 2:30 a.m. Resident (#38) found in floor no apparent injury. Family (MPOA) needs to be notified"" and ""fell last noc (night). Be sure he is in middle of bed."" For Resident #77, staff recorded ""Lethargic"". There was no entry for Resident #26. Documentation on the 24-hour shift report for [DATE] for Resident #38 stated, ""Ntd (noted) feet off bed 2X's (two times) throughout night ... call family any time day and night."" For Resident #77, staff recorded, ""Lethargic [DATE]; wouldn't take 6 a.m. meds [DATE] c/o (complaint of) pain; admitted to hosp with UTI."" For Resident #26, staff recorded, ""Restless up in room several X's throughout night."" - 11. Review of the closed record of Resident #87 (identified in the [DATE] physician's progress note as Resident #26's previous roommate) found a nursing note, dated [DATE] at 2:10 p.m., stating, ""CNA reported as she came up the hall (sic) resident had a pillow across his face. ..."" At the time of this occurrence, Resident #87 shared the same 3-bed room with Resident #26, and the third bed was unoccupied. The DON verified, in an interview at 10:30 a.m. on [DATE], there were no other residents in the room at the time of this incident. Review of Resident #26's thinned records from 2009 found the following regarding his interactions with Resident #87: On [DATE] (no time given), "" ... Later, resident came up to nurse's med cart, watched as nurse was attempting to give roommate (Resident #87) his med. Roommate accidentally ran over nurse's foot. Resident then states to nurse (sic) know what you should do /c the 'bastard'. I've popped him a couple of times. (sic) I asked resident if (sic) had hit the roommate, he stated yes. ..."" - 12. Review of Resident #26's care plan, revised on [DATE] with target dates for goal achievement of [DATE], found the following problem (P), goal (G), and interventions (I) with an initiation date of [DATE]: P: ""Mood problem AEB (as evidence by): Resident becomes easily annoyed with staff and others (particularly his roommate) at times R/T (related to) depression, and dementia, psychosis diagnosis, hx (history) of episodes of agitation."" G: ""Will have improved mood state AEB: calmer appearance, with no more then (sic) 2 episodes weekly of becoming easily annoyed with his roommate or any other S/S (signs / symptoms) of depression, anxiety or sad mood by review date."" (The revised review date for this goal was [DATE].) I: ""Assist in developing more appropriate methods of coping and interacting. Encourage to express feelings appropriately, let staff know when s/he (sic) is getting upset; Administer medications as ordered and monitor for side effects, effectiveness; Observed mood patterns and document S/S of depression, anxiety, sad mood; Ongoing assessment, attempt to determine if problems seems to be related to external causes, ie medications, treatments, concerns over diagnosis, noise level or pain; Spend time talking to resident, family. Encourage to express feelings; Assist resident to identify strengths, positive coping skills and reinforce these; Invite to attend activities and encourage participation."" The interdisciplinary team also addressed the following problem, also with an initiation date of [DATE]: ""Potential for increased behavior problems R/T: [DIAGNOSES REDACTED]."" The goal for this problem statement was: ""Resident will continue to have not episodes of socially inappropriate behavior weekly by review date."" (The revised review date for this goal was [DATE].) The interventions included: ""... Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, situations. Document behavior and potential causes; Intervene as needed to protect the rights and safety of others. Approach / speak in calm manner. Divert attention. Remove from situation and take to another location as needed. ..."" The care plan did not describe what these ""socially inappropriate behaviors"" were. There was no evidence to reflect the care plan was revised upon Resident #26's return to the facility on [DATE], to address the need to ""observe / assess for further treatment"" - as directed in the aftercare plan resulting from his stay at the psychiatric hospital. There was no plan to reinstitute either of the monitoring activities that had been in place prior to his transfer to the psychiatric facility (every twenty (20) minutes beginning on [DATE] or direct supervision of the room shared by these three (3) residents at all times beginning on [DATE]) - especially at night. - 13. At [DATE] at 11:00 a.m., the administrator, medical director, DON, social worker (Employee #52), and the clinical care coordinator (Employee 33) were informed the nurse surveyor identified that Residents #38 and #77 were in immediate jeopardy, as Resident #26 returned to the same room following his discharge from the psychiatric hospital, and the facility failed to implement any measures (e.g., additional monitoring / supervision) to ensure the residents in this room were safe. A plan of correction was requested. - 14. A plan of correction, given to the surveyor on [DATE] at 11:20 a.m., was reviewed and returned to the administrator for revision. At 11:40 a.m., a revised plan of correction was given to the surveyor, reviewed, and accepted at 11:45 a.m. The revised plan of correction stated: ""To correct the safety issues identified during the survey this date, with residents (#26), (#18), and (#77), a room change will be made. Resident (#26) will be moved into room (number of room on second floor). Resident (name) who is currently in room (number of room now occupied by Resident #26) will be moved to (number of room previously occupied by Resident #26). ""Monitoring of resident (#26) will be accomplished by the following: Resident will be in a room by himself. This room is located close to the nurses (sic) station in direct line of all traffic. Nurses or Certified Nursing Assistants will check on him on an hourly basis for any abnormal behaviors. Psychiatric evaluation or placement will be pursued if behavior warrants. Documentation of all abnormal behavior will be monitored on a daily basis by nursing staff."" - 15. On [DATE] at 1:30 p.m., after Resident #26 was relocated and this was verified by direct observation, the administrator was notified the immediate jeopardy was lifted. - 16. During an interview on [DATE] at 6:45 p.m., a nursing assistant (Employee #34) confirmed he found a pillow over Resident #77's face at about 12:30 a.m. on [DATE]. He indicated he had last checked on the resident at 12:00 a.m. on [DATE]. He documented twenty (20) minute checks on Residents #26 and #38 from 1:00 a.m. through 6:20 a.m. on [DATE]. (A copy of this documentation was provided by the DON on [DATE] at 10:40 a.m.) - 17. On [DATE] at 9:00 a.m., the administrator presented evidence that inservices were held [DATE] with staff who provide care to Resident #26. The memorandum on which this inservice was documented, issued by the DON, had in its subject line: ""Precautions related to (Resident #26)"". In the body of the memorandum was: ""(Resident #26) needs to be monitored every hour for behaviors that may affect self or others and documented on appropriate form. (Resident #26) needs to be documented on each shift in the nurses notes related to behaviors whether there are any or not. ""Concerns for (Resident #26) possibly being of danger to other residents has (sic) prompted this."" The bottom of the memorandum contained the signatures of nursing staff. - The facility also revised the care plan for Resident #26 on [DATE], to include the following: P - ""Potential for increased behaviors (physical aggressive (sic) staff or residents) (sexual inappropriate (sic) with staff) (attempting to harm residents) R/T (related to) [DIAGNOSES REDACTED]."" G - ""Resident will have less than weekly episodes of socially inappropriate behaviors by review date."" G - ""Resident will have no episodes of attempting harm other residents through review date."" Interventions included: ""Nursing staff will do hourly checks on resident for behaviors. Nurses will document q (every) shift on behaviors; Resident has been moved to a private room. Psychiatric evaluation and treatment as ordered."" .",2014-01-01
11539,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2010-09-03,520,J,,,LWGO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of self-reported events, staff interview, review of quality assessment and assurance (QAA) committee meeting minutes offered by the facility, medical record review, review of incident / accident reports, and review of the facility's policy and procedure room transfers, the facility's quality assessment and assurance (QAA) committee failed to implement an action plan to ensure the safety of residents sharing a room with Resident #26, upon his return from a psychiatric hospital after being evaluated for possible aggressive tendencies towards others. Resident #26 shared a 3-bed room with Residents #38 and #77. On the early morning of [DATE], staff responding to Resident #26's call light found Resident #38 on the floor positioned with his pads, bed linens, and positioning wedge placed on and under him as if he were still in bed; Resident #38 was not capable of having transferred out of bed himself. On the late night of [DATE], staff found Resident #38's legs had been repositioned in bed in a different position than one in which staff had put him during their previous rounds. The nurse directed staff to monitor all residents in this room every twenty (20) minutes, because Resident #38 was not physically able to move himself, Resident #77 was not physically able to independently transfer out of his own bed, and Resident #26 was behaving in a suspicious manner. During these monitoring rounds, in the early morning hours of [DATE], staff found Resident #38's legs again had been repositioned, and staff found a pillow had been placed over the face of Resident #77. In [DATE], Resident #26 had shared this same room with another resident (#87) who was also found by staff at that time to have a pillow placed over his face. In response to these findings, the facility met with Resident #26's guardian, who agreed to allow him to be evaluated at a psychiatric hospital. Prior to his transfer on [DATE], the facility stationed a staff member in the room at all times to monitor the residents for safety. Resident #26 returned to the facility on [DATE], to the same room shared with Residents #38 and #77. Although the aftercare plan from the psychiatric hospital included the recommendation that the nursing home ""observe / assess need for further treatment"", the facility failed to review / revise Resident #26's care plan to address this. Upon his return, no additional supervision and/or assistive devices were put into place to monitor Resident #26 (especially at night) and/or ensure the ongoing safety of Residents #38 and #77. This placed Residents #38 and #77 in immediate jeopardy. The facility's QAA committee failed, upon Resident #26's return to the facility, to implement measures to ensure the safety of Residents #38 and #77, even though staff strongly suspected Resident #26 of having removed Resident #38 from his bed on the early morning on [DATE], repositioned Resident #38 in his bed on the late evening of [DATE], and placed a pillow over the face of Resident #77 on the early morning of [DATE], especially in light of having found a previous roommate of Resident #87 with a pillow over his face in [DATE]. Facility census: 87. Findings include: a) Residents #26, #38, and #77 1. Observation, during tour beginning at 9:30 a.m. on [DATE], found Residents #26, #38, and #77 sharing the same 3-bed room. - 2. On [DATE] at 10:25 a.m., review of events self-reported by the facility to the State survey and certification agency during the previous three (3) months revealed the following ""unusual occurrence"": ""On [DATE] at 2:30 a.m. the C.N.A. (certified nursing assistant) had entered the room to respond to Resident (#26) call light when Resident (#38) was found on floor beside his bed. Resident (#38) was found on floor still covered in blankets with pink pad under him and wedge cushion behind his back. "" ... due to Resident (#38) need for total assistance with ADL's that (sic) this incident did not appear to be the result of the resident falling out of bed. There is concern that he may have had assistance from his roommate. ... Residents in room will be monitored by staff at more frequent intervals. ... ""Another incident occurred in this same room on the this same date of [DATE] where Resident (#77) was observed by nursing staff with a pillow over his face during the early a.m. (morning) interval checks. Resident (#77) did not know how the pillow got on his face. There were no apparent injuries to either resident."" According to a message confirmation report, this ""unusual occurrence"" was faxed to the State survey agency at 2:45 p.m. on [DATE]. - 3. Review of the medical records for Residents #38 and #77 found entries in the nursing notes relating the same information as stated in the unusual occurrence report mentioned above. - Review of Resident #38's most recent resident assessment, a Medicare 14-day assessment with an assessment reference date (ARD) of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He was alert with long and short term memory problems, he was not oriented to person, place, or season, he was unable to communicate with others, and he was totally dependent upon staff for all ADLs, including bed mobility and transferring. - Review of Resident #77's most recent resident assessment, a quarterly assessment with an ARD of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE]. He was alert and oriented and independent with his cognitive skills for daily decision-making, and he required extensive assistance with bed mobility and transfers, did not ambulate, and was totally dependent on staff for locomotion. His [DIAGNOSES REDACTED]. - Review of Resident #26's most recent resident assessment, a quarterly assessment with an ARD of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE]. Resident #26 was alert, oriented to person, place, and season, had short-term memory problems, and his cognitive skills for daily decision-making were assessed as being ""modified independence""; he was independent with ADLs. His [DIAGNOSES REDACTED]. - Review of nursing notes in Resident #26's record found no entry by the nurse on the night shift from [DATE] to [DATE]. An entry, recorded by the nurse during the night shift from [DATE] to [DATE] (at 2:00 a.m. on [DATE]), stated, ""Resident up most of the night walking around the room. Denies pain or discomfort."" - Review of Resident #26's Plan of Care Kardex for the month of [DATE] found several notes recorded by nursing assistants, starting on [DATE], regarding Resident #26's behavior towards his roommates. On [DATE] (no time or shift noted), a nursing assistant wrote: ""Res (resident) was standing behind the curtain between his bed and (Resident #38 ' s) bed, ask (sic) him what he was doing & Resident stated he wasn't doing anything. CNA (initials of nursing assistant) ask (sic) him to go lay down in his bed or if he couldn't sleep to sit in his chair, that he just couldn't mess with his Room-mate (sic) (Resident #38) or Room-mates (sic) things. He said all right."" Another note on [DATE] (identified as being written on the 7:00 a.m. to 3:00 p.m. shift) stated, ""Res stands behind curtains when your (sic) trying to give care to roommate."" On [DATE], a nursing assistant wrote: ""Res standing behind the curtain when giving care to roommate"" Another entry (no date / time) stated, ""Resident got upset when taking roommate to Bathroom (sic)."" - On the reverse side of Resident #26's [DATE] ADL flow record, a nursing assistant wrote, on [DATE], ""Resident behind curtain looking and trying to see the patient when staff was giving care."" - Review of the physician's progress notes for Resident #26 found the following entries: - On [DATE]: ""I was called last night by (facility) to call (name of administrator), which I did. She related they had a concern about (Resident #26), that in the room he has 2 other roommates, (Resident #38) and (Resident #77). (Resident #38) was found in the floor twice reported by staff. (Resident #38) is not able to move himself. The staff became suspicious then they went over to see (Resident #77) and a pillow was on his head. When they asked (Resident #77) if he was ok (sic) he said yes (sic) and they asked him how the pillow got there (sic) and he related he did not know how. (Resident #26) had been up during the night. He had gone to the bathroom, (sic) in the morning it was reported to (name of administrator) that something suspicious was going on and they fear it would be (Resident #26). They discussed it with the daughter (of Resident #26) who was upset. They discussed there was (sic) odd behaviors that had gone on with he (sic) and (Resident #87 - previous roommate who is now deceased ) (sic) however they did not get along. I called to talk to the daughter and she was at (facility). She wanted me to come down and talk to her (sic) which I did, this was about 8pm. ... I told her we should have an evaluation by doctor in (name of psychiatric hospital). ..."" (Interview with the administrator, on the morning of [DATE], verified that Resident #38 was found on the floor only once, contrary to what was stated above, although his feet were found to have been moved towards the side of the bed on two (2) separate occasions - which the resident was not capable of doing himself.) - On [DATE]: ""We had a family conference today with the daughter, sister, (name of regional ombudsman), Director (sic) of nurses and myself. We discussed (Resident #26). My recommendation is that he got to (city name) to be evaluated. ... I did discuss with her (daughter / guardian of Resident #26) the night before that he and (Resident #87 - previous roommate no longer at the facility) had some disagreements ... At one time there was a pillow that was found beside (Resident #87) and a pillow was found over his face. ... She knows (Resident #38) was found in the floor. He can not (sic) move himself. Then (Resident #77) was found with a pillow over his head. ... The daughter understands we did not see (Resident #26) do this. We do not know what happened. ... I told her to be safe it was important for him to evaluated. ..."" - 4. A quality assurance (QA) committee plan of correction, generated on [DATE] and provided for review to the surveyor by the facility's administrator at 8:00 a.m. on [DATE], revealed the incident involving Resident #38 occurred on the night shift that ran from [DATE] to [DATE], and the incident involving Resident #77 occurred on the night shift that ran from [DATE] to [DATE]; they did not occur within the same 8-hour shift on [DATE]. This [DATE] QA committee plan of correction stated: ""On Monday morning, [DATE], (name) DON (director of nursing) was notified by the nursing staff that there had been a concern with residents in room (Number of room shared by Residents #26, #38, and #77) on Sunday and in the early morning hours of Monday. At approximately 2:30 a.m. resident (#26) had rung his call bell. When the staff responded they observed resident (#38) lying in the floor. When they asked resident (#26) what he needed he said 'nothing'. Resident (#38) was lying in the floor with his under pads, covers and wedge cushion in place. On [DATE] at approximately 11:30 p.m. resident (#38) was observed with his feet over the right side of the bed and at 12:15 a.m. on [DATE] resident (#38) was again observed with his feet over the left side of the bed. Resident (#77) was observed at 12:30 a.m. with a pillow over his face. ... ""INVESTIGATION FINDINGS AND INTERVENTIONS TO CORRECT THE PROBLEM: ""- Resident (#38) is totally dependent upon staff for bed mobility, transfers, ADLS (activities of daily living) and feeding. ""- Call bell is in place for resident (#38) at all times; however, resident does not use call bell independently. ""- Resident (#38) is turned and repositioned q2hrs (every two hours) by staff. ""- Resident (#77) voices needs and wants to staff, rings call bell independently, requires extensive assist of one with bed mobility, transfers with two and dressing, personal hygiene and bathing with the assist of one. ""- Resident (#26) is independent with all ADLs, mobility, ambulates through out (sic) the facility independently, voices needs and wants to staff and rings call bell for assistance as needed. ""- Resident (#26) has documented behaviors related to past roommates. ..."" According to the administrator, due to Resident #26's past behaviors towards roommates and Resident #38's inability to move on his own and his position on the floor with covers and wedge in place, staff questioned whether Resident #26 was involved in removing Resident #38 from bed to floor and his moving feet over the sides of the bed. Staff also questioned whether Resident #26 placed the pillow over Resident #77's face. Checks of the room shared by these three (3) residents were made every twenty (20) minutes for the remainder of the night shift ending on the morning of [DATE]. Staff communicated with the responsible parties of all residents involved and made arrangements to transfer Resident #26 to a psychiatric hospital for evaluation. Until this transfer could be accomplished, the facility assigned a staff member to remain at all times in the room shared by these three (3) residents, since the responsible parties of the residents all refused to allow their family member to be relocated for safety. - 5. Resident #26's guardian agreed to allow him to be transferred to a psychiatric unit for evaluation. According to the nursing notes, the resident was transferred from the facility to the psychiatric hospital at about 2:30 p.m. on [DATE]. - 6. Resident #26 was readmitted to the facility on [DATE] and was placed back into the same room with his previous roommates, Residents #38 and #77. Review of the aftercare plan from the psychiatric hospital, dated [DATE], found the resident was initially admitted for agitation, aggression, and sexually inappropriate behavior. Under the heading ""Patient Treatment Goals / Progress"", staff at the psychiatric hospital wrote: ""Patient has not displayed any agitation or aggression since admission and had not had any sexually inappropriate behavior for several days."" Under the heading ""Diagnosis"" was written: ""Axis I: Dementia, AD ([MEDICAL CONDITION]) type /c (with) depressed mood and behavioral disturbance. Axis II: Schizoid Personality D/O (disorder). ... Axis IV: NH (nursing home) placement. ..."" Under the heading ""Discharge Recommendations / Plan"" was written: ""NH to observe and assess for further treatment."" An interview with the administrator, on [DATE] at 4:00 p.m., found Resident #26's guardian refused to allow the resident to be moved. She also indicated Residents #38's responsible party and Resident #77 (who had capacity) did not want to change rooms. - 7. In an interview on [DATE] at 8:30 a.m., the medical director acknowledged her awareness of the situation regarding Resident #26. She had questions about the ability to move a resident to another without the health care decision maker's consent. On [DATE] between 8:30 a.m. and 9:45 a.m., intermittent observations made with the medical director found all three (3) residents together in the same room with no specific measures in place to ensure the safety of the roommates. At 9:45 a.m. on [DATE], the facility's ""Resident Transfer"" policy (no date), was requested of and provided for review by the administrator. Review of the policy revealed the following: ""Policy: 1. Transfer of Residents Within the Manor: ... C. In the case of emergency the facility reserves the right to make a move but will notify the resident or their responsible party."" ""Procedure: Transfer of Patient: ... 8. Due to changes in patient's condition, we reserve the right to transfer the patient to the area where we can best meet his or her needs."" This information was shared with the medical director. - 8. One (1) of the facility's social workers, (Employee #52) was interviewed at 10:30 a.m. on [DATE]. She sat in on a meeting with Resident #26, his daughter / guardian, and his sister on [DATE]. The resident was sent to the psych unit to determine if he had tendencies to be physically aggressive towards other residents. - 9. Employee #19 (the LPN who completed the above-referenced incident reports for Residents #38 and #77) provided handwritten notes, as well as documentation of observations made by staff of Residents #26 and #38 every twenty (20) minutes from 1:00 a.m. to 6:20 a.m. on [DATE], to the director of nursing (DON) on [DATE]. The DON provided copies of this documentation for review to this nurse surveyor at 10:40 a.m. on [DATE]. The first note stated: ""On [DATE] at 2:30 AM (sic) The CNA's were responding to (Resident #26)'s call light. When they went into the room he said he didn't need anything and that's (sic) when they found (Resident #38) lying on the floor. On the (L) side of the bed on his back. He still had his pads underneath him & his blankets were wrapped around him and the wedge they place behind his back was tucked under his (L) side. Both bedrails were also up. Prior to him being in the floor (sic) (Resident #38) was positioned in bed on his (R) side /c (with) the wedge behind his back. I am letting you know about this b/c (because) I find his falling in the floor suspicious and don't see how he could have ended up in the floor like that on his own."" - The second note stated: ""Just for clarification - On ,[DATE] @ 2:30 AM (Resident #38) was in the floor on the (L) side of his bed in between the bed & the rocker chair. He was on his back /c pads underneath him & blankets wrapped around his legs & the wedge was underneath his (L) hand side. His bed rails were up & his bed was in (sic) low position. Prior to him being in the floor he was positioned on his (R) side /c wedge behind him on the left side of his back. ""On ,[DATE] @ 1130 PM when walking up the hall his feet were pulled to the (R) side of the bed and he was laying (sic) on his (R) side. ""At 12:15 AM - now [DATE] Resident was lying on (R) side and his feet were pulled to the (L) side of the bed. ""After that is when we found (Resident #77) with the pillow on his face. ""That's (sic) when I initiated the 20 minute check paper for the CNA to fill out."" (During an interview on [DATE] at 5:15 p.m., Employee #19 verified her statements.) - 10. The DON, when interviewed on [DATE] at 10:45 a.m., reported a resident service provider (RSP) was assigned to provide one-on-one supervision of Resident #26 from [DATE] at 2:30 p.m. through [DATE] at 2:30 p.m., when he went to the hospital. The DON reported became suspicious of Resident #26's behavior after she reviewed the 24-hour shift reports for [DATE] and [DATE], which indicated Resident #38 was found on the floor during the early morning hours on [DATE] (on the night shift starting on [DATE]) and was found two (2) times with his feet hanging off the bed during the night shift starting on [DATE]. Documentation on the 24-hour shift report for [DATE] stated, ""[DATE] 2:30 a.m. Resident (#38) found in floor no apparent injury. Family (MPOA) needs to be notified"" and ""fell last noc (night). Be sure he is in middle of bed."" For Resident #77, staff recorded ""Lethargic"". There was no entry for Resident #26. Documentation on the 24-hour shift report for [DATE] for Resident #38 stated, ""Ntd (noted) feet off bed 2X's (two times) throughout night ... call family any time day and night."" For Resident #77, staff recorded, ""Lethargic [DATE]; wouldn't take 6 a.m. meds [DATE] c/o (complaint of) pain; admitted to hosp with UTI."" For Resident #26, staff recorded, ""Restless up in room several X's throughout night."" - 11. Review of the closed record of Resident #87 (identified in the [DATE] physician ' s progress note as Resident #26's previous roommate) found a nursing note, dated [DATE] at 2:10 p.m., stating, ""CNA reported as she came up the hall (sic) resident had a pillow across his face. ..."" At the time of this occurrence, Resident #87 shared the same 3-bed room with Resident #26, and the third bed was unoccupied. The DON verified, in an interview at 10:30 a.m. on [DATE], there were no other residents in the room at the time of this incident. Review of Resident #26's thinned records from 2009 found the following regarding his interactions with Resident #87: On [DATE] (no time given), "" ... Later, resident came up to nurse's med cart, watched as nurse was attempting to give roommate (Resident #87) his med. Roommate accidentally ran over nurse's foot. Resident then states to nurse (sic) know what you should do /c the 'bastard'. I've popped him a couple of times. (sic) I asked resident if (sic) had hit the roommate, he stated yes. ..."" - 12. Review of Resident #26's care plan, revised on [DATE] with target dates for goal achievement of [DATE], found the following problem (P), goal (G), and interventions (I) with an initiation date of [DATE]: P: ""Mood problem AEB (as evidence by): Resident becomes easily annoyed with staff and others (particularly his roommate) at times R/T (related to) depression, and dementia, [MEDICAL CONDITION] diagnosis, hx (history) of episodes of agitation."" G: ""Will have improved mood state AEB: calmer appearance, with no more then (sic) 2 episodes weekly of becoming easily annoyed with his roommate or any other S/S (signs / symptoms) of depression, anxiety or sad mood by review date."" (The revised review date for this goal was [DATE].) I: ""Assist in developing more appropriate methods of coping and interacting. Encourage to express feelings appropriately, let staff know when s/he (sic) is getting upset; Administer medications as ordered and monitor for side effects, effectiveness; Observed mood patterns and document S/S of depression, anxiety, sad mood; Ongoing assessment, attempt to determine if problems seems to be related to external causes, ie medications, treatments, concerns over diagnosis, noise level or pain; Spend time talking to resident, family. Encourage to express feelings; Assist resident to identify strengths, positive coping skills and reinforce these; Invite to attend activities and encourage participation."" The interdisciplinary team also addressed the following problem, also with an initiation date of [DATE]: ""Potential for increased behavior problems R/T: [DIAGNOSES REDACTED]."" The goal for this problem statement was: ""Resident will continue to have not episodes of socially inappropriate behavior weekly by review date."" (The revised review date for this goal was [DATE].) The interventions included: "" ... Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, situations. Document behavior and potential causes; Intervene as needed to protect the rights and safety of others. Approach / speak in calm manner. Divert attention. Remove from situation and take to another location as needed. ..."" The care plan did not describe what these ""socially inappropriate behaviors"" were. There was no evidence to reflect the care plan was revised upon Resident #26's return to the facility on [DATE], to address the need to ""observe / assess for further treatment"" - as directed in the aftercare plan resulting from his stay at the psychiatric hospital. There was no plan to reinstitute either of the monitoring activities that had been in place prior to his transfer to the psychiatric facility (every twenty (20) minutes beginning on [DATE] or direct supervision of the room shared by these three (3) residents at all times beginning on [DATE]) - especially at night. - 13. At [DATE] at 11:00 a.m., the administrator, medical director, DON, social worker (Employee #52), and the clinical care coordinator (Employee 33) were informed the nurse surveyor identified that Residents #38 and #77 were in immediate jeopardy, as Resident #26 returned to the same room following his discharge from the psychiatric hospital, and the facility failed to implement any measures (e.g., additional monitoring / supervision) to ensure the residents in this room were safe. A plan of correction was requested. - 14. A plan of correction, given to the surveyor on [DATE] at 11:20 a.m., was reviewed and returned to the administrator for revision. At 11:40 a.m., a revised plan of correction was given to the surveyor, reviewed, and accepted at 11:45 a.m. The revised plan of correction stated: ""To correct the safety issues identified during the survey this date, with residents (#26), (#18), and (#77), a room change will be made. Resident (#26) will be moved into room (number of room on second floor). Resident (name) who is currently in room (number of room now occupied by Resident #26) will be moved to (number of room previously occupied by Resident #26). ""Monitoring of resident (#26) will be accomplished by the following: Resident will be in a room by himself. This room is located close to the nurses (sic) station in direct line of all traffic. Nurses or Certified Nursing Assistants will check on him on an hourly basis for any abnormal behaviors. Psychiatric evaluation or placement will be pursued if behavior warrants. Documentation of all abnormal behavior will be monitored on a daily basis by nursing staff."" - 15. On [DATE] at 1:30 p.m., after Resident #26 was relocated and this was verified by direct observation, the administrator was notified the immediate jeopardy was lifted. - 16. During an interview on [DATE] at 6:45 p.m., a nursing assistant (Employee #34) confirmed he found a pillow over Resident #77's face at about 12:30 a.m. on [DATE]. He indicated he had last checked on the resident at 12:00 a.m. on [DATE]. He documented twenty (20) minute checks on Residents #26 and #38 from 1:00 a.m. through 6:20 a.m. on [DATE]. (A copy of this documentation was provided by the DON on [DATE] at 10:40 a.m.). - 17. On [DATE] at 9:00 a.m., the administrator presented evidence that inservices were held [DATE] with staff who provide care to Resident #26. The memorandum on which this inservice was documented, issued by the DON, had in its subject line: ""Precautions related to (Resident #26)"". In the body of the memorandum was: ""(Resident #26) needs to be monitored every hour for behaviors that may affect self or others and documented on appropriate form. (Resident #26) needs to be documented on each shift in the nurses notes related to behaviors whether there are any or not. ""Concerns for (Resident #26) possibly being of danger to other residents has (sic) prompted this."" The bottom of the memorandum contained the signatures of nursing staff. - The facility also revised the care plan for Resident #26 on [DATE], to include the following: P - ""Potential for increased behaviors (physical aggressive (sic) staff or residents) (sexual inappropriate (sic) with staff) (attempting to harm residents) R/T (related to) [DIAGNOSES REDACTED]."" G - ""Resident will have less than weekly episodes of socially inappropriate behaviors by review date."" G - ""Resident will have no episodes of attempting harm other residents through review date."" Interventions included: ""Nursing staff will do hourly checks on resident for behaviors. Nurses will document q (every) shift on behaviors; Resident has been moved to a private room. Psychiatric evaluation and treatment as ordered."" - 18. The facility's QAA committee failed, upon Resident #26's return to the facility, to implement measures to ensure the safety of Residents #38 and #77, even though staff strongly suspected Resident #26 of having removed Resident #38 from his bed on the early morning on [DATE], repositioned Resident #38 in his bed on the late evening of [DATE], and placed a pillow over the face of Resident #77 on the early morning of [DATE], especially in light of having found a previous roommate of Resident #87 with a pillow over his face in [DATE].",2014-01-01
6,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2017-06-02,164,D,0,1,ELSQ11,"Based on random observation and staff interview the facility failed to ensure the personal privacy and confidentiality of a resident's medication records. Resident identifier: #82. Facility census: 116. Findings include: a) Resident #82 On 05/18/17 at 6:30 a.m., Licensed Practical Nurse (LPN) #55 left Resident #82's medication record open in a way the information could be read by a person other than the nurse passing the medications. The LPN entered the resident's room and returned to the cart on at least two (2) occasions and continued to leave the medication information exposed. At 6:33 a.m. on 05/18/17, LPN #55 agreed the information was exposed.",2020-09-01
7,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2017-06-02,241,E,0,1,ELSQ11,"Based on observation and staff interview, the facility failed to maintain residents' dignity during the dining experience for seven (7) of twenty-seven (27) residents in the main dining room. A random observation revealed obviously soiled linens were not changed in a timely fashion for Resident #25. Facility census: 116. Resident identifiers: Resident #25, #124, #77, #71, #21, #49, #192 and #68. Findings include: a) Resident #25 During a random observation on 05/17/17 at 6:20 a.m., Nurse Aide (NA) #36 placed a sheet over Resident #25's blanket. Observation revealed a brown stain covering an area of approximately two feet by two feet (2 ft x 2 ft). The nurse aide looked at the area and verbalized, Oh, Lord. Another observation at 9:20 a.m., revealed Resident #25 sitting at the bedside eating his breakfast. The stained blanket was again visible from the doorway. Upon request, the Center Nurse Executive (CNE) completed an observation and interview. Resident #25, interviewed at 9:22 a.m., said he was sitting at his bedside the night before and had spilled his coffee, making a big mess. The resident said the accident occurred about 10:00 p.m. on 05/16/16. At 9:24 a.m., the CNE acknowledged the blanket should have been changed at the time of the spill, and as the resident sat at the bedside for breakfast, staff had additional opportunity to change the blanket. b) Residents #124, #77, #71, #21, #49, #192, and #68. A dining observation on 05/16/17 from 11:10 a.m. and 12:45 p.m., revealed Residents #124, #77, and #21 sat in the dining room and did not converse with other residents or staff during the pre-meal interim or during mealtime. Staff asked residents meal preferences, but did not converse in a social manner. Resident #71, sat at a table alone. She verbalized she had no friends, and felt lonely. At another table, Resident #21 did not have a tablemate. She looked around the room at other residents, but neither staff nor residents spoke to her throughout the course of the dining experience. Resident #77 and #125 required assistance to eat, but staff did not interact with the residents in a social manner. Residents #49 and#192 were seated at the same table. Resident #192 was served at 12:11 p.m., but Resident #49 did not receive his tray until 12:19 p.m. Staff began serving the long table nearest the kitchen at 12:02 p.m. At 12:08 p.m., Resident #68 verbalized in a crying tone, I can't (cannot) wait much longer. At that time, tablemates called out to the administrator who was standing nearby. The resident, with a frowned expression, informed her she had only ordered soup and did not understand why she had not received it. An observation and interview with the clinical nurse educator (CNE), toward the end of the meal, at about 12:30 p.m. on 05/16/17, agreed staff did not interact socially with residents who did not have a tablemate or who were not socializing with others. The CNE verbalized some residents were capable of socializing, but acknowledged staff should have interacted with them on a social level.",2020-09-01
9,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2017-06-02,278,D,0,1,ELSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete an accurate quarterly minimum data set (MDS) assessment to reflect the resident's pain medication regimen. This was true for one (1) of thirty-two (32) residents reviewed. Resident identifier: #100. Facility census: 116. Findings include: a) Resident #100 Review of Resident #100's medical records revealed a physician's orders [REDACTED]. Record review revealed Resident #100 continued to receive this medication through the month of (MONTH) (YEAR). Review of a quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 05/05/17, revealed Resident #100 did not receive scheduled pain medication. On 06/01/17 at 5:46 p.m., the MDS coordinator, Registered Nurse (RN) #108, agreed the quarterly MDS with an ARD of 05/05/17 should have been coded to identify Resident #100 received scheduled pain medication.",2020-09-01
10,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2017-06-02,279,E,0,1,ELSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, resident interview, and family interview, the facility failed to develop a care plan for a resident with bruises and a skin tear (#92), failed to establish measurable objectives to monitor a resident's progress related to activities (#143) and range of motion (ROM) (#43), and failed to develop a care plan timely related to assessing a thrill and bruit for a resident with an arteriovenous graft (#45). Four (4) of thirty-two (32) residents on the sample were affected. Facility census: 116. Resident identifiers: #143, #92, #45, and #43. Findings include: a) Resident #143 The resident's medical record included a Brief Interview for Mental Status (BIMS) on which the resident scored ten (10), indicating moderate cognitive impairment. During a Stage 1 interview on 05/16/17 at 2:12 p.m., a family member verbalized Resident #143 liked to attend Church services. Resident #143, interviewed on 05/31/17 at 1:56 a.m., exhibited symptoms of confusion related to time, but with inquiry, verbalized she liked to go to church and wanted to go every Sunday. The resident expressed she did not care what denomination it was, just Christian. The care plan noted Resident #143 would indicate satisfaction in daily routine/activities as evidenced by verbalizing satisfaction, increase in affect during participation, increased focus and attention to activities of choice. The interventions included to assist, as needed, to activities of interest church, parties, socials, crafts, pets, music, and reading. During review of the resident's care plan with the administrator on 05/31/17 at 6:12 p.m., when asked how the facility measured increased affect, focus and attention, the administrator acknowledged the goal was not measurable, shook her head in a yes motion, and said, I get you. b) Resident #92 An observation on 5/16/17 at 1:08 p.m., revealed bluish red bruised from Resident #92's hand to upper arm. A bandage was present on the left forearm, and the resident verbalized he had obtained a skin tear. During a wound care observation, on 05/23/17 at 11:40 a.m., the nurse removed a bandage from the resident's left great toe, revealing an open wound on the top of the toe. A physician's orders [REDACTED]. The care plan, reviewed on 05/24/17, revealed no evidence of bruising or of the toe wound. MDS Coordinator #108, interviewed at 2:01 p.m., voiced the nurses updated the care plans as new orders, concerns arose. She reviewed the care plan and verified a care plan was not developed related to the bruises or the skin tear on Resident #92's toe. c) Resident #45 Review of medical records revealed Resident #45 had an Arteriovenous Fistula (AV) for [MEDICAL TREATMENT] treatments. Review of the physician's orders [REDACTED]. The resident continued to have an AV fistula site at the time of the current survey beginning 05/15/17. Review of the resident's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. There was no evidence the facility monitored the resident's AV fistula after 11/22/16 until a new order written on 05/02/17. On 05/24/17 at 4:21 p.m., Registered Nurse (RN) #126 stated the resident had had an AV fistula site for [MEDICAL TREATMENT] for at least three (3) years. Review of an article Caring for a patient's vascular access for [MEDICAL TREATMENT] in the 2010 Lippincott[NAME] & Wilkins medical surgery text book found it included a nurse should check the AV fistula site for patency at least every eight hours. On 05/24/17 at 3:18 p.m., the facility administrator agreed monitoring the bruit and thrill was not routinely completed, nor did the care plan include monitoring the AV fistula from 11/22/16 until 05/02/17. d) Resident #43 Review of the resident's medical record on 05/22/17 found the resident had [DIAGNOSES REDACTED]. The significant change minimum data set (MDS) with an assessment reference date (ARD) of 03/17/17, assessed contractures of the right upper extremity. Review of the care plan found it contained a focus where it identified her right side extremities were weaker than the left. The care plan identified that she had contractures of the right shoulder, elbow, wrist and hand; however, the care plan failed to provide individualized and measurable goals they wished to achieve related to the right upper extremity contractures. The care plan failed to provide individualized interventions to help prevent further loss of range of motion and/or other negative outcomes, related to the right upper extremity contractures. The care plan contained no directives for range of motion or for any splint/orthotic devices. During an interview on 05/22/17 at 4:01 p.m., Director of Rehabilitation Services #52, said (MONTH) (YEAR) was the last time occupational therapy (OT) had her on its case load. Their goals were for passive and active range of motion to the right upper extremities for three (3) sets of ten (10) repetitions daily to establish a contracture management program. Their goal was for her to work up to tolerate a right hand orthotic for four (4) hours per day. The final long term goal was to discharge her to the restorative program with 100% staff training for contracture management program. She said the director of nursing (DON) was the head of the restorative nursing department. In an interview on 05/22/17 at 4:22 p.m., the director of nursing (DON) said this resident used to have a Posey roll, and she used to have restorative nursing services for range of motion with restorative aides; however, she no longer received restorative services. She said she felt the regular nursing assistants on the units did enough range of motion during activities of daily living to make it count for range of motion. She said that the resident had a Posey roll for her right hand prior to a week-long hospital stay the first week in (MONTH) (YEAR), but it had not been re-ordered since the (MONTH) hospitalization . She said most likely restorative services order fell through the cracks and was not re-ordered upon her (MONTH) return to the facility. The DON provided a copy of the resident's care plan on 05/22/17 at 4:45 p.m. When asked to provide any evidence of care planned individualized and measurable goals and interventions related to contracture management, no further evidence was provided. Observation and interview with the resident on 05/23/17 at 9:41 a.m. found she could use her left hand and try to stretch out the fingers on her right hand. The little finger and the thumb of the right hand were not contracted. The three middle fingers on the right hand were contracted, and she could not stretch them out with her left hand. Those three fingers were bent downward, and then pointed back toward the wrist. She wore no splint device or palm protector when observed in Stage I of the Quality Indicator Survey.",2020-09-01
11,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2017-06-02,280,D,0,1,ELSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to review and/or revise care plans timely related to an arteriovenous (AV) graft (#159), restorative ambulation (#141), and an actual falls (#115). This practice affected three (3) of thirty-two (32) Stage 2 residents. Facility census: 116. Resident identifiers: #159, #141, and #115. Findings include: a) Resident #159 Medical record review revealed a physician's orders [REDACTED]. Upon inquiry, Health Information Management Coordinator (HIMC) #50, interviewed on 05/30/17 at 4:03 p.m., provided information noting the AV graft had been placed when the resident went to the hospital on [DATE] and returned to the facility on [DATE]. Further review of the medical record revealed the resident had discharge on 03/11/17 and re-entered the facility on 03/13/17. The care plan was not revised until after completion of the resident's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 04/11/17. The care plan noted a revision date of 04/17/17 to reflect Resident #159 had an arteriovenous graft. MDS Coordinator #108, interviewed on 05/24/17, verbalized it was the nursing staff's responsibility to update and/or revise the care plan with a change in condition. b) Resident #141 During a Stage 1 interview on 05/16/17 at 2:57 p.m., Resident #141 verbalized he was supposed to receive restorative therapy for ambulation, but had not received it for three (3) weeks. The resident voiced a concern that he lost strength and endurance when he did not walk with restorative. Medical record review revealed a current care plan with a goal to walk 150 feet two (2) times a day, six (6) days a week, initiated on 04/28/17. The intervention, dated 09/22/16, indicated Resident #141 would ambulate 200 feet twice a day, six (6) days a week. During an interview on 05/24/17 at 2:36 p.m., Nurse Aide (NA) #23 reviewed the restorative records and said Resident #141 walked 150 feet two (2) times a day. Additionally, the physician's orders [REDACTED]. An interview with the director of nursing, immediately following the interview with NA #23, confirmed the care plan intervention had not been revised to reflect the physician's orders [REDACTED].> c) Resident #115 Medical record review on 05/30/17 found this resident, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. According to the medical record, she experienced actual falls on 04/30/17, 05/03/17, and 05/12/17. On the first and second occurrence she was found lying on the floor by the bed. On the latter occurrence, she slipped out of the wheelchair and onto the floor. Review of the current care plan found this resident was care planned as at risk for falls. The care plan was silent for any revisions showing the resident was not only at risk for falls, but that she had sustained actual falls since coming to the facility. In an interview with minimum data set (MDS) Registered Nurse #68 on 05/31/17 at 10:39 a.m., she reviewed the care plan and said they did not revise care plans to include the actual falls a resident experiences. When interviewed on 05/31/17 at 10:50 a.m., the administrator acknowledged that the care plan was not revised to include that she had sustained actual falls since admission to the facility. She said they typically update new interventions they may have added after a fall, but they do not revise the care plan to include either that the resident had sustained actual falls, or the dates of the falls.",2020-09-01
12,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2017-06-02,282,E,0,1,ELSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, visitor/family interview, staff interview, observation, and policy review, the facility failed to ensure services were provided according to the resident's written plan of care for five (5) of thirty-two (32) Stage 2 residents. Residents #27 and #141 did not receive planned restorative services. Resident #143 did not participate in activities as identied on her care plan. Resident #163 did not receive treatments in accordance with the plan of care, and Resident #124 did not receive foods in accordance with her plan of care. Facility census: 116. Resident identifiers: Resident #27, #143, #141, #163 and #124. Findings include: a) Resident #27 A medical record review related to accidents revealed a physician's orders [REDACTED].#27 required limited assistance of one (1) person for ambulation, and utilized a walker and/or wheelchair. The assessment noted the resident was not steady, but able to stabilize without staff assistance. [DIAGNOSES REDACTED]. Further review of the medical record revealed a physician's orders [REDACTED]. - nursing to assist resident to ambulate 80 feet two (2) times a day with roll walker and gait belt using CGA (contact guard assist) six (6) days a week. Re-evaluate in 90 days and as needed. -Restorative nursing to assist with bilateral lower extremity (BLE) exercises using two pound (2 lb) weight-hip flexion, knee extension three (3) sets times ten (10) repetitions daily six (6) days a week. Re-evaluate in 90 days and as needed. The care plan indicated Resident #27 was at risk for falls and risk for bleeding related to anticoagulant therapy. It noted the resident demonstrated a deficit in ambulation related to (r/t) functional deterioration resolved on 04/01/17 and revised on 04/20/17. During an observation and interview with Resident #27 on 05/31/17 at 4:32 p.m., the resident voiced she stayed in her room most of the time, but walked to the bathroom. Upon inquiry, the visitor said she was at the facility about three (3) times a week, and was adamant that Resident #27 had not been walking in the hallway with restorative nursing. Restorative Nursing records, reviewed from 05/01/17 through 05/24/17 indicated Resident #27 only walked one (1) time a day on the days she received restorative ambulation. Additionally, no evidence was present to indicate the resident received restorative as ordered 05/10/17 through 05/24/17. No data was entered for the dates of 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, or 05/23/17. The restorative nursing for bilateral lower extremity exercises yielded no data for 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, and 05/23/17. Nurse Aide (NA) #37, interviewed on 05/23/17 at 12:48 p.m., verbalized only the restorative nurse aides walked with Resident#27 in the hallway for restorative care. NA #23, interviewed on 05/24/17 at 2:36 p.m., verified the residents did not receive restorative therapy if no data was present. The restorative/rehabilitative nursing program plan indicated the skilled functional area deficit was required because a potential for decline existed and to maintain the current level of function. Program instructions indicated therapy be completed six (6) days a week. The interim center nurse executive (CNE), interviewed on 05/24/17 at about 3:30 p.m., confirmed restorative care had not been provided as directed by the plan of care. b) Resident #143 A Stage 1 family interview, on 05/16/17 at 1:58 a.m., revealed Resident #143 preferred church activities. The family member said the resident liked to attend church services and went every Sunday morning. The minimum data set (MDS) with an assessment reference date (ARD) of 05/05/17 noted a brief interview for mental status (BIMS) score of ten (10) which indicated moderate cognitive impairment. The preferences for customary and activity section noted it was important for the resident to receive a snack between meals, music, reading, doing things with groups of people, participating in favorite activities, and participating in religious activities or practices. The recreation assessment noted the resident enjoyed small groups. The resident's care plan indicated Resident #143 enjoyed being in the dining room for lunch and socializing with staff. A nursing assessment dated [DATE] noted the resident watched television (TV) and attended church on occasion. The recreation assessment noted the resident seemed to enjoy games and religious activities. Observations on 05/15/17 at 1:46 p.m., 05/16/17 at 8:28 a.m., 05/31/17 at 10:04 a.m., revealed no evidence of participation in activities. Nurse Aide (NA) #73, interviewed on 05/31/17 at 10:23 a.m., said she was not sure what Resident #143 liked as she usually always worked on the south hallway. NA #100, interviewed at 10:24 a.m., said she had not really worked the hallway too long, and was not sure what the resident liked to do. The NA verbalized the resident did not come out of the room much and wanted staff to leave her alone. The (MONTH) (YEAR) recreation log indicated Resident #143 participated with socialization daily, attended a special event on one occasion (05/24/17), hydration cart two (2) of 28 opportunities,and participated with reminiscence daily. It noted she attended church on four (4) of seven (7) opportunities, Bible study two (2) of four (4) opportunities, and gospel music two (2) of five (5) opportunities. Recreation Assistant (RA) #34, interviewed on 05/31/17 at 1:33 p.m., said church services were usually in the morning and Bible study in the evenings. The RA reviewed the calendar and said the facility did have church services every Sunday morning and of four (4) opportunities, no evidence was present to indicate Resident #143 had been invited to two (2) of them. Upon inquiry, the RA said the floor staff were not provided information as to whom should attend each event. During an interview and observation on 05/31/17 at 1:56 p.m., Resident #143 was eating lunch in her room. She said she had lasagna for lunch (one small piece of pasta remained on her plate) and they put too much mayo (mayonnaise) on the salad. She exhibited confusion as to person and place, and talked about her mother. When asked what time she would like to get up she said around eight o'clock (8:00 a.m.). Upon inquiry as to what activities she liked, Resident #143 said she went to church every Sunday. The resident said she did not care what denomination it was, just Christian. On 05/31/17 from 4:37 p.m., until 4:59 p.m., during a dining observation, Resident #143 sat at a table with two (2) other residents. She was seated at the corner of the table, attempting to eat a sandwich with a spoon. The residents did not interact. RA #34, NA #116, RA #22, NA #79, Bookkeeper #20, and Activity Director/Guest Services #36 assisted in the dining room. No one conversed with the resident. RA #34 verbalized the social activity in which Resident #143 participated daily at 4:30 p.m., was the pre-meal activity. Upon inquiry, the recreation assistant verbalized Resident #143 would be included as having participated in the activity, even though no one socially interacted with the resident. The activity log and observations were reviewed with administrator on 05/31/17 at 6:12 p.m. She acknowledged the noted lack of participation related to the number of opportunities for things which were important to Resident #143. Additionally, she verbalized acknowledgement related to lack of socialization for the dining event and concurred the resident did not receive activities in accordance with the plan of care. c) Resident #141 During a Stage 1 interview, on 05/16/17 at 2:57 p.m., Resident #141 verbalized he was supposed to receive restorative therapy for ambulation, but had not received it for three (3) weeks. The resident voiced a concern that he lost strength and endurance when he did not walk with restorative. The medical record revealed a current care plan with a goal to walk 150 feet two (2) times a day, six (6) days a week, initiated on 04/28/17. Additionally, the physician's orders [REDACTED]. During an observation and interview with Resident #141, on 05/23/17 at 9:15 a.m. the resident said he had his bath and was waiting for the nurse to provide his pain relief therapy. He verbalized restorative would walk him after that. At 12:28 p.m., the resident said, No one has walked me yet. and at 2:30 p.m., the resident said he had not yet walked. The resident said he had walked three (3) times the previous week, but had not walked at all the three (3) weeks prior to that. Resident #141 expressed he felt like he was losing his strength. Another observation at 5:53 p.m. revealed the resident sleeping bed. Nurse Aide (NA) #34, interviewed at 12:48 p.m. on 05/23/17, said Resident #141 walked with restorative aides, but they get pulled to the floor a lot so it doesn't (does not) get done. The NA said the resident had no routine, just slept most of the day. The NA voiced the resident did not usually refuse to walk, but it took him a while because his legs shake. The NA reported it took about forty-five (45) minutes to an hour to walk him from his room to the doorway of the conference room and back, and that he usually took a break. The NA verbalized the resident walked on a good week four (4) times. An interview with Nurse Aide (NA) #23 on 05/24/17 at 2:36 p.m., reviewed the restorative records and said Resident #141 was supposed to walk 150 feet two (2) times a day. The NA verbalized restorative noted the shift and time of resident participation and/or refusal. The NA said if no entry was present then restorative did not ask the resident to ambulate. Upon request, the NA reviewed the (MONTH) (YEAR) and (MONTH) (YEAR) activity participation log and confirmed no evidence was present to indicate services had been offered on the dates of 05/01/17, 05/02/17, 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/13/17, 05/14/17, 05/15/17, 05/16/17, 05/19/17, 05/21/17, 05/22/17, and 05/23/17. Additionally, no evidence was present to indicate it was offered twice on the dates of 05/17/17, 05/18/17, 05/20/17 and 05/24/17. The log noted Resident #141 had refused on the 3-11 shift on 05/03/17, 05/04/17 and 05/08/17, with no evidence it was offered during the 7-3 shift. The (MONTH) (YEAR) log indicated Resident #141 did not receive restorative ambulation services for the dates of 04/07/17, 04/09/17, 04/10/17, 04/13/17, 04/14/17, 04/15/17, 04/16/17, 04/18/17, 04/19/17, 04/21/17, 04/22/17, 04/25/17, 04/27/17 04/29/17 or 04/30/17. Additionally, NA #23 confirmed no evidence was present to indicate ambulation services had been offered twice daily on 04/08/17, 4/17/17, 04/23/17 and 04/28/17. Resident was out of facility for one (1) date and refused (R) for four (4) of twenty-three (23) opportunities. The interim Center Nurse Executive (CNE) interviewed on 05/24/17 at about 3:00 p.m., confirmed Resident #141 had not received restorative services as per the plan of care. d) Resident #163 A medical record review revealed a physician's orders [REDACTED]. Another order noted to cleanse an unstageable wound to the right second toe with wound cleanser and apply sure prep daily. Observation of wound care on 05/18/17 at 10:21 a.m., with Licensed Practical Nurse (LPN) # --- revealed the Stage 2 pressure ulcer present on the Resident #163's coccyx. Upon inquiry as to whether the unit charge nurses completed treatments, the LPN said she completed the treatments for the entire facility. The medical record and treatment administration records, reviewed for (MONTH) and (MONTH) (YEAR), revealed no evidence the treatment for [REDACTED]. No evidence was present to indicate the Stage 2 coccyx wound treatment was completed for seven (7) of forty (40)opportunities, on seven o'clock in the morning until three o'clock in the afternoon (7:00 a.m. - 3:00 p.m.) shift on the dates 05/14/17, 05/13/17, 05/12/17, 05/11/17, 04/15/17, 04/16/17 and 04/17/17. The CNE reviewed the medical record on 05/31/17 and confirmed omission of data. No evidence was present to indicate the facility had provided the wound care treatments as directed by the plan of care. e) Resident #124 The medical record was reviewed on 06/01/17. [DIAGNOSES REDACTED]. She weighed only 82 pounds on 05/26/17, as recorded on the computer weight records. Medications ordered included [MEDICATION NAME] fifteen (15) milligrams daily to help increase her appetite. Review of the current comprehensive care plan included interventions for weight maintenance or gain for this edentulous resident on pages twenty-one (21) and twenty-two (22) of the care plan. Interventions included eight (8) ounces of buttermilk with meals three (3) times per day at her request, and ice cream with lunch and dinner. She was observed eating her evening meal on 06/01/17 at 5:25 p.m. She had no buttermilk. Rather, dietary sent her a carton of skim milk. Dietary sent her a small bowl covered with cellophane wrap that looked like pudding. When asked if that was ice cream, the resident replied in the negative. When asked if she liked buttermilk with her meals, she replied in the affirmative. Nursing Assistant (NA) #11 was in the room at the time, assisting the resident's room-mate with her tray. NA #11 asked the resident if she would like some buttermilk, and the resident replied I sure would! NA #11 said she would also get her some ice cream from the dietary kitchen. An interview was conducted with the dietary director #89 on 06/01/17 at 5:50 p.m. Upon inquiry as to whether he received dietary orders for this resident to have eight (8) ounces of buttermilk with each meal, and ice cream with lunch and dinner, he slightly thumbed through some half sheets of dietary orders and diet changes he kept in a folder. He said he would have to check his file to see if he received an order for [REDACTED]. On 06/01/17 at 7:05 an interview was conducted with the director of nursing and the administrator. The administrator said the dietary director sent the buttermilk tonight after surveyor intervention. The administrator said the dietary director found he had ice cream, and sent ice cream to the resident this evening after we had discussed it. She agreed that the care plan directed this resident to receive eight (8) ounces of buttermilk with each meal, and ice cream daily with each lunch and dinner meal.",2020-09-01
14,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2017-06-02,312,D,0,1,ELSQ11,"**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 provide necessary services to maintain good grooming for two (2) of thirty-two (32) sampled residents. Resident #117 had unshaven facial hair. Resident #76 had long unkempt hair, was unshaven, and wore the same clothing on successive days. Resident identifiers: #117 and #76. Facility census: 116. Findings include: a) Resident #117 Observation on 05/16/17 at 2:16 p.m. found this [AGE] year old resident had numerous long white hairs on her chin and lower jaw area. On 05/23/17, review of the most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) 04/13/17, found her Brief Interview for Mental Status (BIMS) score was three (3), indicating severe cognitive impairment. She required limited assistance with personal hygiene. Review of the resident's care plan found a focus statement identifying she was at risk for decreased ability to perform activities of daily living (ADL) functions due to generalized weakness, fluctuation in cognition/dementia with behaviors, and multiple other disease processes. Interventions included to provide assistance as needed, as the ADLs might fluctuate. Observation on 05/23/17 at 12:45 p.m. found she still had long white hairs on her chin and lower jaw area. When asked about the resident's chin whiskers, Nurse Aide (NA) #59 replied that just this morning he commented that the resident's beard was longer than his. He said he would shave her right away, and he did. During an interview on 05/23/17 at 4:20 p.m., the administrator said this resident's ADL abilities fluctuated due to her behaviors and dementia. No further information was provided about the resident's facial hair. b) Resident #76 A Stage 1 observation on 05/15/17 at 1:47 p.m., revealed Resident #76 was unshaven, and his hair was long, uncombed and unclean. Another observation on 05/16/17 at 8:30 a.m., revealed his beard growth remained unshaved. On 05/17/17 at 3:24 p.m., the resident's hair remained long and disheveled, but he had been shaved. The nurse said the hospice aide had provided care. An observation on 05/23/2017 at 9:09 a.m., found Resident #76 in bed awake, watching a game show on his roommate's television. The fingernails on his right hand had dark brown debris beneath them. His hair was uncombed, and he had not been shaved. When asked how often he would like to be shaved, he replied he would like shaved right now. The resident voiced he preferred to be shaved daily. At 11:56 a.m., the resident had been shaved, and his hair combed. Another observation at 2:25 p.m. revealed his nails had been clipped and cleaned. Nurse Aide (NA) #135, on 05/23/17 at 2:28 p.m., said the resident had gotten weak and now staff did most of his care. She verbalized the hospice aide had provided his care this date. The minimum data set (MDS) with an assessment reference date (ARD) of 05/15/15 indicated Resident #76 required extensive assistance with dressing, eating, toilet use and personal hygiene. The assessment indicated the resident had impairment on both sides of his upper and lower extremities. The resident received hospice services for end of life care related to end stage [MEDICAL CONDITIONS]. The care plan, revised on 05/10/17, noted Resident #76 required assistance with activities of daily living (ADLs) with a goal to improve current level of ADL functions by next review. A hospice nurse aide (NA) provided care two (2) times a week. Licensed Practical Nurse (LPN) #62, interviewed on 05/24/17 at 1:26 p.m., said the resident was very noncompliant, but most of the time would let staff provide care if asked. She said the nurse would re-direct him if he refused for the nurse aides. An observation with the interim clinical nurse educator (CNE) on 05/24/17 at 4:10 p.m., revealed Resident #76 was still wearing the same clothing placed on him by the hospice NA on 05/23/17. During an observation on 06/01/17 at 11:27 a.m., Resident #76 was sitting in the dining room for lunch. His hair had been cut and he was clean shaven. The resident said he preferred his hair cut short. During a discussion with the CNE on 06/01/17 at 6:30 p.m., she said the facility was responsible to care for the resident on the days the hospice aide did not come to the facility. She voiced the resident had a decline, was dependent upon staff for care, and the resident should have been shaved by the facility nurse aides on the days a hospice staff member was not in the building.",2020-09-01
15,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2017-06-02,315,D,0,1,ELSQ11,"Based on a random observation and staff interview, the facility failed to provide care in a manner to prevent urinary tract infections. A staff member placed washcloths in the bathroom sink basin in preparation for incontinence care, creating a potential for introducing potential pathogens into the resident's urinary tract. This practice affected one (1) resident for whom incontinence care was observed. Facility census: 116. Resident identifier: #163. Findings include: a) Resident #163 During a wound care observation on 05/18/17 at 10:21 a.m., Licensed Practical Nurse unfastened the resident's brief revealing the resident had had an incontinence episode. Nurse Aide (NA) #102 obtained a stack of washcloths, placed them in the bathroom sink basin, and turned on the water. The NA wrung the washcloths and laid them on the left side of the sink near the faucet handle. NA #102 dried her hands, picked up the washcloths and gave them to Licensed Practical Nurse (LPN) #72 who utilized them to perform peri-care.",2020-09-01
16,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2017-06-02,318,D,0,1,ELSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to ensure one (1) of three (3) residents reviewed for range of motion received services to help prevent further decline. Resident #43 had contractures of the right hand, wrist, elbow, and shoulder, but had no range of motion or orthotics ordered to help prevent further decline or other negative outcomes. Resident identifier: #43. Facility census: 116. Findings include: a) Resident #43 Review of the resident's medical record on [DATE] found the resident's [DIAGNOSES REDACTED]. Review of the admission minimum data set (MDS) with an assessment reference date (ARD) of [DATE], found she came to the facility with contractures of the right hand, wrist, elbow, and shoulder. Review of the most recent comprehensive assessment with an ARD of [DATE], found she was assessed with [REDACTED]. The facility assessed her as having received no therapy services, no restorative nursing services, and no hand or wrist splint/orthotic device during the look back period. Her Brief Interview for Mental Status (BIMS) score was eleven (11), indicating moderately impaired cognitive functioning. On [DATE] at 4:45 p.m., the administrator provided a copy of the resident's current care plan. Review of the care plan found a focus statement related to the right side extremities being weaker than the left, and contractures of the right shoulder, elbow, wrist, and hand. However, there was no goal related to what the facility hoped to achieve related to contracture maintenance, and no interventions on how the facility planned to ensure no worsening of the contractures, or no negative outcomes related to the contractures. During an interview on [DATE] at 4:01 p.m., Director of Rehabilitation Services #52 said this resident first began therapy services [DATE] through [DATE]. Their old record keeping was done on paper and they had transferred to electronic documentation sometime in (YEAR). She reviewed the numerous times this resident had physical therapy (PT) and/or occupational therapy (OT) services in (YEAR) and found the following: - She was on PT and OT caseload [DATE] through [DATE]. - She received PT and OT services [DATE] through [DATE]. - She again received PT and OT services [DATE] through [DATE]. - She was on PT caseload [DATE] through [DATE]. Director of Rehabilitation Services #52 said she assumed the resident had a hospitalization in there somewhere. - She received OT services [DATE] through [DATE]. - She received PT and OT services [DATE] through [DATE]. Director of Rehabilitation Services #52 said they screened every patient in the facility at least every three (3) months at the time their quarterly assessments were due, and on patients after they sustained a fall. She said they also have a HEY program whereby they keep referral sheets at every nursing station. She said if any employee within the facility had a concern about a resident's functioning, they could communicate their concerns to therapy by utilizing the referral sheets. Director of Rehabilitation Services #52 said they screened this resident on [DATE] after she was readmitted to the facility following a psychiatric inpatient admission. They found that she was able to propel in a wheelchair around the facility and there was no change in functional transfers. Upon inquiry, she said the last time OT had her on case load was (MONTH) (YEAR). At that time, OT had goals for passive and active range of motion (ROM) to the right upper extremities, ten (10) repetitions for three (3) sets daily to establish a contracture management program. OT also had goals for her to tolerate a right hand orthotic for two (2) hours initially, with the goal to tolerate it long-term for four (4) hours. The final long-term OT goals were to discharge the resident to the restorative program with 100% staff training for the contracture management program. She said the director of nursing (DON) was the head of the restorative program. In an interview on [DATE] at 4:15 p.m., the DON said therapy did not say to pick her back up for restorative when they did her screening upon her return to the facility following that (MONTH) psychiatric hospitalization . Upon inquiry, she said this resident had not received restorative services since her return to the facility on or around [DATE]. On [DATE] at 4:22 p.m., during a joint interview with the DON and Director of Rehabilitation Services #52, the DON said the resident used to have a Posey roll. She said the resident also used to receive restorative services with the restorative aides. The DON said that formerly this resident had physician orders [REDACTED]. The DON said the old orders expired, and there were no new admission orders [REDACTED]. She said PT completed a screening upon her return to the facility from the hospital, and did not order restorative services or the Posey hand roll. She said that in all likelihood this may have fallen through the cracks. The DON said she felt that nursing assistants did enough range of motion during the activities of daily living to make it count for range of motion. The DON and Director of Rehabilitation Services #52 said they would check with therapy the next day to see if they want her picked back up again for restorative services. On [DATE], interviews with Nurse Aides (NA) #64 and #38, at 5:30 p.m. and at 5:35 p.m., respectively, revealed they were trained in nurse aide classes to exercise limbs of residents who had paralysis. NA #38 said she was assigned to provide care for this resident that day. She said she knew to exercise the affected limb. She said she has had no instructions to apply any type of splint, orthotic, carrot, or Posey roll to the affected hand. During an interview with the resident on [DATE] at 9:41 a.m., she demonstrated that she could use her left hand to try to stretch out the fingers on her right hand. The little finger and the thumb of the right hand were not contracted. The three (3) middles fingers on the right hand were contracted and she could not stretch them out. The three fingers were bent downward, and then pointed back toward the wrist. The fingernails that could be visualized were trim. There was no odor noted. During an another interview with Director of Rehabilitation Services #52 on [DATE] at 1:20 p.m., she said that OT looked at the resident and determined that she had not sustained any decline in functionality. She said they picked her back up on caseload. On [DATE] at 8:15 a.m., during an interview with OT #11, a box with a Posey hand splint inside was noted on her desk that had the resident's name written in black marker on the outside of the box. OT #11 said she assessed the resident yesterday and saw no decline in the functionality of the resident's right hand. She said the functionality of the resident's hand was the same as it was during the time she had most recently received therapy services. When asked what would happen if the resident did not wear the Posey hand splint, she said the palm of the resident's hand would become macerated, and her contracted fingertips could intrude into the palm. When asked if she would always need to wear a device of that type, she replied in the affirmative. She said the contracture would not correct itself at any time in the future, so it would be a lifetime need for the device. When asked whether the restorative service aides or the regular aides on the floor would apply the Posey when she was discharged from OT, she said only the restorative aides would apply it. She said the regular aides on the floor did not apply orthotics, and would not do so unless the policy changed sometime in the future to allow the aides to do so. She agreed that upon her return from the hospital in March, that she should have been picked up again for restorative and for the orthotic, and she was not.",2020-09-01
17,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2017-06-02,329,D,0,1,ELSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident remained free of unnecessary drugs. The physician ordered a reduction of Resident #9's [MEDICATION NAME] more than two (2) months after the pharmacist recommended the reduction. Two (2) days after the ordered reduction, the medication was increased without any evidence the increase was needed. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #9. Facility census: 116. Findings include: a) Resident #9 Review of a pharmacist's consultation report with a date of 02/09/17 revealed a recommendation to the physician to re-evaluate the continued use of [MEDICATION NAME] at the current dose of 0.5 mg (milligrams) at bedtime. The physician responded to this recommendation on 04/13/17, which was sixty-four (64) day after the initial recommendation. On 04/13/17 the physician ordered a reduction to 0.25 mg at bedtime for one (1) week and then discontinue the [MEDICATION NAME]. On 04/15/17 the physician discontinued [MEDICATION NAME] 0.25 mg at bedtime and restarted [MEDICATION NAME] 0.5 mg at bedtime. Review of the behavioral flow sheet for (MONTH) of (YEAR) did not reveal behaviors related to anxiety. Review of nursing notes between 04/13/17 and 04/15/17 did not reveal documentation of the resident experiencing anxiety. On 05/31/17 at 1:36 p.m., the director of nursing (DON) agreed the records did not reveal any indication of a need for increasing the [MEDICATION NAME].",2020-09-01
19,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2017-06-02,362,E,0,1,ELSQ11,"Based on observation, staff interview, resident interview, and review of the dining schedule, the facility failed to ensure sufficient staffing to prepare and serve food in the scheduled timeframes. This practice affected twelve (12) residents served in their rooms during lunch dining. Facility census: 116. Resident identifiers: Residents #93, #125, #34, #43, #41, #121, #22 #104, #189, and #63 Findings include: a) Residents #93, #125, #34, #43, #41, #121, and #22 The dining schedule indicated lunch meals were served to areas as follows: -- fine dining 11:25 a.m. -- rehab (restorative) 11:30 a.m. -- south hall 12:10 p.m. -- south hall 12:15 p.m. -- east hall 12:20 p.m. -- east hall 12:30 p.m. -- north hall 12:35 p.m. -- north hall 12:40 b) During a random observation on 06/01/2017 12:50 p.m., a staff member announced by the overhead page Lunch is now being served on east hall. Within a few minutes the food cart was delivered and parked by the entrance near the main dining room. The time was 30 minutes later than noted on the schedule for the first cart. The dining schedule indicated the trays shoud have been served at 12:20 p.m. Observation revealed no resident on the hallway had a meal tray. c) At 12:55 p.m. on 06/01/17, observation of the South Hall revealed staff passing trays from the food cart on the hallway. The dining schedule indicated the floor trays were served at 12:10 p.m. NA#34 was heard informing Residents #93 and #125 they would be helped soon. Upon inquiry, the NA said ten (10) residents required assistance with meals and two (2) nurse aides passing trays. The dining schedule indicated the meal trays would be served at 12:10 p.m. - At 12:58 p.m., NA #2 passed a tray to Resident #34 and began to feed her. - At 12:58 p.m., Registered Nurse (RN) #126 and the interim CNE said they would assist. The CNE passed a tray to Resident #93 and fed her. - At 1:02 p.m., RN #126 passed a tray to Resident #125 - At 1:07 p.m., RN #108 passed a tray to Resident #121 - At 1:10 p.m., Resident #41 was asleep, her meal tray on the table in front of her. A small fly/gnat was crawling on her sandwich. The resident had not eaten her meal. - Resident #64 was asleep with her tray uneaten - At 1:14 p.m., Resident #22 had not eaten. At this time NA #34 entered the room and encouraged the resident to eat. - At 1:15 p.m., NA #103 tried to awaken Resident #43, but the resident was not responding. NA #2 talked loudly to the resident and rubbed her chest in circular motions with his hand. The resident barely opened her eyes for a second and went back to sleep. - At 1:19 p.m., LPN #94 walked by the room of Resident #41 and #107, but did not stop or try to awaken the residents who had not started eating their meals. The resident response list on the South Hall, dated 06/01/17 at 2:52 p.m., identified Resident #93, Resident #67, and Resident #77 were totally dependent for eating. Those who required extensive assistance included Residents #125, #107, #117,#129, #34, #18, #5, and #9. d) Residents #104, #189 and #63 Observation of the North Hall meal tray service at 1:20 p.m., revealed staff passing meal trays - At 1:26 p.m. - meal tray served to Resident #104 who was fed by NA #41. - At 1:27 p.m. - trays passed to Resident #189 and #63 by Health Information Management Coordinator (HIMC) #50 e) During an interview with Resident #92 on 05/16/17 at 10:28 a.m., the resident voiced meal services were often late, 30 to 60 minutes. f) During an interview with the interim Center Nurse Executive on 06/01/17 at 2:15 p.m., when asked to whom the facility addressed staffing concerns, the CNE said the restorative nursing staff were pulled to the floor. She further added that staff in other disciplines, who were also nurse aides, were sometimes pulled to the floor. Additionally, the CNE verbalized staff from sister facilities would help. When asked how staff functioned during the evening meals and on weekends when administrative staff were not in the facility to assist, the CNE said the weekend manager assisted. ( Four (4) administrative staff assisted on two (2) hallways during the lunch meal observation on 06/01/17.)",2020-09-01
20,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2017-06-02,428,D,0,1,ELSQ11,"Based on record review and staff interview, the facility failed to act upon a pharmacist's recommendation in a timely manner. This was true for two (2) of five (5) residents reviewed for unnecessary medications. The physician did not respond to a pharmacist's recommendation for Resident #9 for over two (2) months. For Resident #45, the resident continued to receive the medication Reglan nearly three (3) months after it should have been discontinued. Resident identifiers: #9 and #45. Facility census: 116. Findings include: a) Resident #9 Review of a pharmacist's consultation report dated 02/09/17 revealed a recommendation to the physician to re-evaluate the continued use of Clonazepam (a psychoactive medication) at the current dose of 0.5 mg (milligrams) at bedtime. The physician responded to this recommendation on 04/13/17, which was 64 days from the initial recommendation. On 05/31/17 at 1:36 p.m., the director of nursing (DON) agreed the physician's response to the pharmacist's recommendation was not timely. b) Resident #45 A pharmacist review dated 02/09/17 identified Resident #45 received Reglan 5 mg every 8 hours and was also taking Protonix 40 mg daily with both medications being for gastroesophageal reflux disease (GERD). The pharmacist's recommendation was to consider tapering the Reglan while continuing the Protonix. The physician accepted the recommendation with a modification of discontinuing the Reglan on 02/25/17. Review of the Medication Administration Record [REDACTED]. On 05/31/17 at 1:36 p.m., the DON agreed the resident continued to receive Reglan after the physician noted to discontinue the medication on 02/25/17.",2020-09-01
21,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2017-06-02,431,E,0,1,ELSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of the Centers for Disease Control (CDC) and Prevention guidelines, and review of manufacturer's guidelines, the facility failed, in collaboration with the pharmacist, to ensure the safe and effective use of medications. A multi-dose vial of Purified Protein Derivative (PPD - a test to aid in the detection or [DIAGNOSES REDACTED]. This had the potential to negatively impact the safety and/or potency of the medication, and had the potential to affect any resident who might receive an injection from this vial. One (1) of two (2) medication storage room refrigerators contained a vial of PPD serum that was not labeled when initially opened. Facility census: 116. Findings include: a) East wing medication room refrigerator Observation of the East wing medication room refrigerator on 05/17/17 at 7:56 a.m., accompanied by Licensed Nurse (LN) #55, found an opened, partially used vial of Purified Protein Derivative (PPD) serum which contained no date indicating when it had first been opened. When full, the vial contained enough serum for ten (10) tests. The nurse said the vial should have been dated when it was first opened, so that staff could determine how long the vial had been in use. She said they should discard all opened vials of PPD after they were opened for thirty (30) days. She immediately discarded the opened vial of PPD. During an interview with the director of nursing on 05/17/17 at 5:00 p.m. she said the nurse informed her of the opened undated vial of PPD. She said their policy directed that all multi dose vials be dated initially when opened, and discarded in accordance with the manufacturer's guideline. The Centers for Disease Control and Prevention (CDC) guidelines include, If 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. The Aplisol PPD manufacturer's guidelines includes, Vials in use for more than thirty (30) days should be discarded due to possible oxidation and degradation which may affect potency.",2020-09-01
22,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2017-06-02,441,E,0,1,ELSQ11,"Based on observations, staff interview, 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 failed to utilize proper hand hygiene, failed to utilize personal protective equipment (PPE) when required and/or dispose of PPE properly, and failed to handle medication properly. These practices affected nine (9) of the one hundred sixteen (116) residing in the facility and had the potential to affect additional residents. Facility census: 116. Resident identifiers: #25, #189, #127, #76, #104, #42, #31, #163, and #158. Findings include: a) Residents #25, #189, #127, #76, #104, and #42 During a lunch meal observation, Nurse Aide (NA) #75 touched items in the room of Resident #25, returned to the cart, poured a cup of coffee and placed it on top of the cart. The NA entered the room of Resident #189 who was in contact isolation for clostridium difficile (a highly contagious organism). The NA did not don personal protective equipment (PPE) prior to entering the room. Upon completion of the tray set-up, NA #75 washed her hands for a count of eight (8) seconds. The NA exited the room and poured coffee for Resident #68. Without performing hand hygiene, the NA passed trays to Resident #76 and assisted NA #135 with Resident #104. Upon completion, the NA washed her hands for a count of seven (7) seconds, then passed a tray to Resident #42. b) Resident #25 On 05/17/17 at 6:20 a.m., Nurse Aide (NA) #36 performed care for Resident #25. Upon completion, the NA bagged soiled items. With the same gloves the NA pulled up the resident's covers, picked up the bed remote from the floor and attached the call bell to the bed cover. c) Resident #163 During a wound care observation on 05/18/17 at 10:21 a.m., Nurse Aide (NA) #102 assisted Licensed Practical Nurse (LPN) #72 with wound care. The resident held Resident #163's hands. When the nurse unfastened the resident's brief, she found the resident had an incontinence episode. The NA removed her gloves and without performing hand hygiene exited the room. Upon return, the NA went to the bathroom and donned gloves. Upon completion of care, the NA removed her gloves and exited the room without utilizing hand hygiene. During care, Resident #163 pulled the barrier on the nightstand and a plastic bag with wound care supplies fell to the floor. Upon completion of wound care, LPN #72 removed her gloves and used hand sanitizer. The LPN picked up the plastic bag from the floor which contained gloves and four by four gauze pads. She placed the tube of cream utilized for wound care and the wound care cleanser in the bag. LPN #72 picked up the bag in her right hand and the garbage bag with her left hand and exited the room. She stopped at the treatment cart, placed the bag on top of the cart without first cleansing it, then placed it in the drawer, laying it across the top of other opened bags which contained other residents' supplies, still without cleansing the bag. d) Resident #31 A random observation on 06/01/17 at 4:24 p.m., revealed an isolation cart stationed outside of Resident #31's door. A small trash can, located on the right side of the resident's bed, near the foot of the bed, contained a yellow isolation gown protruding over the top of the garbage can. An isolation mask was located on the floor bedside the bed. Upon request, Licensed Practical Nurse (LPN) #60, completed an observation and said, Not cool. The nurse said the gown should be in a covered container and asked AD #36 to obtain one. The resident was identified as having shingles. e) Housekeeping During a random observation on 05/23/17 from 11:59 a.m. until 12:24 p.m., a bucket of mop water was noted spilled in the hallway at the room of Resident #50. Housekeeping (HSK) #133 and physical therapy assistant (PTA) cleaned the spill using towels to wipe up the contents. They did not wear PPE. Upon completion, HSK #133 wiped her hands down the sides of her uniform pants, as if to further dry them. f) During an interview on 05/30/17 at 2:58 p.m., Registered Nurse (RN) #6, the infection control coordinator, said the facility's policy required staff wash hands for a minimum of twenty (20) seconds. The nurse said the washcloths utilized for peri care should not have been placed in the sink basin, and PPE was required prior to entering the room of the resident in isolation. The RN identified Resident #189's infection as clostridium difficile, which required stringent hand hygiene. The nurse verbalized LPN #72 should have sanitized the bag she picked up from Resident #163's floor, prior to placing it back in the cart, but would have obtained a new bag herself. g) The hand hygiene policy with a revision date of 11/28/16, required staff perform hand hygiene before patient care, before an aseptic (clean) procedure, after any contact with blood or other body fluids even if gloves were worn, after patient care, and after contact with the patient's environment. The policy noted staff might decontaminate with alcohol based rub or wash hands with soap and rub vigorously for 20 seconds, covering all surfaces of hands and fingers. h) Resident #158 During medication administration observations on 05/16/17 at 8:16 a.m. Licensed Practical Nurse (LPN) #132 obtained a box from the drawer of her medication cart which contained Breo Elipta (an inhaler). She carried the box into Resident #158's room, and set the box directly onto the resident's bedside stand. She removed the inhaler and handed it to the resident to use. After the resident finished with the inhaler, LPN #132 placed the inhaler back into its box. She then placed the box directly onto the countertop of the resident's sink while she washed her hands. She then placed the box back into the drawer of the medication cart. During an interview with the director of nursing on 05/17/16 at 5:15 p.m., the risk of possibly transmitting pathogens by not maintaining a barrier between clean objects (medication box) and resident furnishings during the medication pass was discussed. She agreed, and said she would educate the nurse.",2020-09-01
23,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2017-06-02,514,E,0,1,ELSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to maintain complete and accurate medical records. For Resident #190, neurological assessments were incomplete. For Resident #163, documentation regarding treatments, response to pain medication, and a voiding diary were incomplete. For Resident #159, [MEDICAL TREATMENT] communication sheets and activities of daily living (ADLs) date were incomplete. ADL sheets were incomplete for Resident #76 and meal/snack percentages were not documented for Resident #143. This was true for five (5) of thirty-two (32) records reviewed. Resident identifiers: #190, #163, #159, #76, and #143. Facility census: 116. Findings include: a) Resident #190 Review of the resident's medical record on 05/30/17 found he sustained an unwitnessed fall in his room on 04/10/17 at 5:05 p.m. As a result of the fall, he incurred an abrasion and a skin tear to the back of his left arm between his elbow and shoulder. The facility initiated a neurological assessment flow sheet right away. On 04/11/17 at 4:30 p.m. and at 8:30 p.m., the flow sheet was silent for neurological assessments, vital signs, observations, or staff signatures. The assessment resumed on 04/12/17 at 12:30 a.m. On 05/30/2017 at 4:04 p.m., after reviewing the neurological assessment flow sheet, the director of nursing (DON) agreed there was incomplete documentation on 04/11/17 at 4:30 p.m. and at 8:30 p.m. with no documented refusals, and noted the night shift picked it back up as did the day shift, with no abnormalities noted. b) Resident #163 1. Review of the resident's medical record and treatment administration records for (MONTH) and (MONTH) (YEAR), found no evidence the treatment for [REDACTED]. No evidence was present to indicate the Stage 2 coccyx wound treatment was completed for seven (7) of forty (40) opportunities, on seven o'clock in the morning until three o'clock in the afternoon (7:00 a.m. - 3:00 p.m.) shift on the dates 05/14/17, 05/13/17, 05/12/17, 05/11/17, 04/15/17, 04/16/17, and 04/17/17. 2. Further review of the medical record revealed a new order for [MEDICATION NAME] sulfate 20 mg/ml (milligrams per milliliter) administer 0.75 ml sublingually (sl) every hour as needed and was clarified to administer 0.5 ml sl every hour as needed. Pain assessment records revealed no evidence the facility reassessed pain after administration of [MEDICATION NAME] sulfate on 05/18/17, 05/15/17 and 05/08/17, 04/23/17, 04/21/17, 04/18/17, 04/15/17, and 04/12/17. A pain presence monitoring tool was not present for (MONTH) (YEAR). 3. The three (3) day incontinence management diary, dated 04/12/17 through 04/15/17, revealed no data for 9 of 36 opportunities including 7:00 a.m. to 9:00 a.m., 9:00 a.m. to 11:00 a.m., 11:00 a.m. to 1:00 p.m., and 1:00 p.m. to 3:00 p.m. on 04/14/17 and 04/15/17, and 11:00 p.m. to 1:00 a.m. on 04/12/17. c) Resident #159 1. [MEDICAL TREATMENT] communication records, reviewed for the period from 12/15/16 to present, revealed incomplete records for fourteen (14) of fifteen (15) records reviewed. The communication record included a pre-[MEDICAL TREATMENT] assessment for the facility nurse to complete, a middle section for the [MEDICAL TREATMENT] center to complete, and a post-[MEDICAL TREATMENT] assessment for the facility to complete. Incomplete records were found for 05/23/17, 05/20/17, 05/18/17, 05/15/17, 05/12/17, 05/09/17, 05/06/17, 05/04/17, 05/02/17, 12/24/16, 12/22/17, 12/20/16,12/17/16, and 12/15/16. Records between 12/24/16 and 05/02/17 were absent from the [MEDICAL TREATMENT] records. On 06/12/17 at 6:17 p.m., when asked what the facility's responsibility related to the permacath and graft site were, Registered Nurse (RN) #120 verbalized none, and said the [MEDICAL TREATMENT] site managed the line. Further inquiry related to the facility's responsibility for assessing and monitoring the site, RN #120 said the facility did not have a responsibility. Licensed Practical Nurse (LPN) #132 verbalized the facility was required to monitor the bruit and thrill of the graft site. RN #120 reviewed the [MEDICAL TREATMENT] communication records and confirmed they were incomplete. On 05/30/17 at 12:34 p.m., the communication records were reviewed with the interim Center Nurse Executive (CNE), who also confirmed the records were incomplete. The CNE said she did not know how laboratory results were communicated between [MEDICAL TREATMENT] and the facility. The nurse said she thought the [MEDICAL TREATMENT] center did send a report at times and would ask Health Information Management Coordinator (HIMC). The HIMC verbalized at 4:03 p.m., that no additional information was present in the medical record or thinned files. Additionally, HIMC said the graft had been placed on 02/08/17, but the facility did not have an order to monitor for thrill and bruit until 05/24/17. No evidence was present to indicate the bruit and thrill were monitored for the months of February, March, and (MONTH) (YEAR). 2. Activity of daily living records reviewed for (MONTH) (YEAR) revealed omissions of data for meal percentages for 05/30/17, 05/29/17, 05/27/17, 05/26/16, 05/08/17, and 05/06/17. Omissions related to snacks included 05/31/17, 05/30/17, 05/29/17, 05/27/17, 05/26/17, 05/24/17, 05/16/17, 05/09/16, 05/08/16, 05/06/17, and 05/04/17. The interim CNE reviewed the medical record on 06/01/17 and confirmed the record was not complete. d) Resident #76 05/30/17 at 10:24:05 p.m., review of the resident's activities of daily living (ADL) records found incomplete data for bed mobility, transfers, eating, toilet, walking, locomotion, dressing, personal hygiene, bathing, meals, bladder, and bowel for dates 05/07/17, 05/08/17, 05/11/17, 05/12/17, 05/17/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, and 05/24/17. e) Resident #143 Review of the resident's medical record related to nutrition revealed omissions of data for meal percentages and bedtime snacks. The (MONTH) (YEAR) activity of daily living records noted omissions of data for 18 of 93 opportunities for meals on 05/31/17, 05/30/17, 05/26/17, 05/22/17, 05/21/17, 05/20/17, 05/13/17, 05/02/17, and 05/01/17. Snack data omissions included 6 of 31 opportunities for snacks on 05/30/17, 05/29/17, 05/26/17, 05/25/17, 05/05/17, and 05/02/17.",2020-09-01
24,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2019-06-10,558,D,0,1,8Y4111,"Based on observation, resident interview and staff interview, the facility failed to provide appropriate accommodation of needs regarding storage and accessibility of Resident #23's personal items. This was evident for one (1) randomly observed resident. Resident identifier: #23. Facility census: 111. Findings included: a) Resident #23 During initial screening process on 06/02/19 at 2:30 PM, Resident #23's dresser drawer was found to be in disrepair and not functionable. The front of the middle wooden dresser drawer was observed to be busted out, loosely hanging off the base of the drawer only to be attached by one nail in the left-hand corner. The broken drawer was hanging in such a way that it also blocked access to the bottom dresser drawer. On 06/02/19 at 2:33 PM, Resident #23 stated that she could not access her personal items in the middle or bottom dresser drawers due to the front of the middle drawer falling apart and hanging in the way. Resident stated, I told maintenance a while back, and he said he would have to go to into town and get some wood glue to fix the drawer, but he has never come back to fix it. The Resident also stated she had not been able to fully utilize her dresser for quite some time due to the broken dresser drawer. At 9:05 AM on 06/05/19 during an interview, the Administrator agreed the Resident's dresser drawer was in disrepair and inaccessible to Resident, and it needed repaired immediately. The facility's Administrator stated, I will get with our maintenance guy and have him get what ever supplies he will need to fix it today.",2020-09-01
25,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2019-06-10,580,D,0,1,8Y4111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview and policy review, the facility failed to promptly notify the physician when a resident experienced a change in condition. This was true of one (1) of one (1) sample residents reviewed for infections (not UTI or Respiratory). Resident (R#33) refused physician ordered wound dressing for multiple days without the physician being notified. This practice had the potential to effeect a limited number of residents. Resident identifier: R#33. Facility census: 111. Findings included: During the initial tour of the annual Long-Term Care Survey Process, on 06/03/19 at 11:15 AM, Surveyor# observed Resident (R#33) with dried crusted drainage around a small open circular wound site located on the resident's upper abdominal right side. This was identified as a concern for further investigation by Surveyor# due to the open wound drainage and not being covered with a dressing. Review of records, on 06/10/19 at 11:01 AM, revealed R#33's brief interview for mental status (BIMs) score is fourteen (14) indicating the resident is cognitively intact. Pertinent [DIAGNOSES REDACTED]. The resident was admitted to the facility after having incision and drainage (I&D) of abscesses, which developed after having lower-back spinal surgery and after having a cholecystectomy. A cholecystectomy is the surgical procedure to remove a gallbladder. After gallbladder surgery the resident had a drainage tube at the surgical site, on his right upper abdomen, to prevent the build-up of bile, blood, and/or infection. The resident developed an abscess on his right side and another incision and drainage procedure was performed and a drainage tube was again placed to facilitate healing. On 04/04/19, after the drainage tube was removed a new order was given to clean surgical incision to right side with wound cleanser, pat dry, and apply dry dressing every day. Review of the treatment administration record (TAR) revealed daily wound care treatment including a dry dressing was ordered and started on 04/04/19. The wound care and dry dressing was applied daily from 04/04/19 until 04/10/19 when it was documented refused and applied again daily on 04/11/19 until 04/14/19 when it was documented as refused. The wound care treatment and dry dressing was applied daily again on 04/15/19 until 04/18/19 when it was documented refused. The wound care treatment and dry dressing was applied on 04/19/19, 04/20/19, 04/21/19, 04/24/19, 04/27/19, and 04/28/19. On 04/22/19, 04/23/19, 04/25/19, 04/29/19, and 04/30/19 it was documented refused, and on 04/26/19 there was no documentation either way as to refusal or provision of wound care treatment and the dry dressing, the TAR entry was blank. In the month of (MONTH) 2019 the resident had twenty seven (27) opportunities to have wound care treatment and a dressing applied daily and had the ordered treatment randomly eighteen (18) times. There was no wound care treatment provided at all during the month of May. According to the TAR, R#33 refused wound care treatment and daily dressings twenty-nine (29) days in the month of May, and two (2) days there was no documentation either way as to refusal or application of wound care or the dry dressing, the TAR was blank on those two days. According to the TAR, R#33 refused treatment on (MONTH) first, second, third, and fourth; and on 06/05/19 the wound nurse obtained an order to discontinue treatment due to refusals. From the time of the order until the order was discontinued there were sixty-two (62) opportunities to provide daily wound care treatment as ordered and it was documented treatment was provided as ordered on only eighteen (18) days, and three (3) days there was no documentation either way as to refusal or provision. There was no documented evidence the physician was notified of the resident's refusals until 06/05/19, when the order was discontinued. An interview with the wound nurse, Licensed Practical Nurse (LPN#84), on 06/10/19 at 11:44 AM, revealed LPN#84 said she kept trying to get R#33 to allow her to provide the wound treatment but he always refused. LPN#84 said the resident would let her clean and measure the wound weekly but not provide treatment and place a dry dressing on it daily as it was ordered. This surveyor requested evidence or documentation showing the resident refused wound care treatment, the physician was notified about the refusals of treatment, and R#33 was provided education concerning the importance of wound care and infection control. LPN#84 asked the nurse unit manager (LPN#61), to help review R#33's medical records for any of the requested documentation, while she finished the interview with this surveyor. LPN#84 said she was aware there was still some occasional drainage from the wound site. LPN#84 agreed the physician should have been notified concerning the resident's refusal of daily wound care and dressings. LPN#84 said she thought she contacted the physician sometime during the middle of (MONTH) and told the physician about the resident's refusal of treatment, however she said she did not document the conversation as she should have. When asked what instructions the physician gave her, LPN#84 said, I was to keep encouraging the resident to allow dressing changes. LPN#84 was asked by this surveyor if any other nursing staff tried to get the resident to comply with the ordered wound care treatment, such as the Center Nurse Executive (CNE), formerly known as the Director of Nursing or the Nurse Practitioner (NP). A Nurse Practitioner works in the facility three to four days a week and was available to see the resident. The wound nurse said she did not speak with the CNE or the NP or any other staff concerning R#33's refusals of wound care treatment. LPN#84 said she did not ask anyone else to see or speak to the resident to see if they might get R#33 to comply with the wound care treatment and/or to educate the resident on the importance of proper wound care and/or to ensure the resident understood. After review of the resident's medical records the nurse unit manager (LPN#61) stated she could find no documentation concerning refusal or non-compliance with the wound care treatment. LPN#61 said there was documentation concerning refusing care and non-compliance in other areas, but nothing concerning wound care. The facility was unable to provide any documentation or evidence that patient education was provided to the resident or any documentation that showed the physician was notified of the resident's refusals of wound care treatment. On 06/10/19 at 01:10 PM, interview with the resident revealed the wound still has some occasional drainage, but not as much as it did. When asked if anyone had explained to him the importance of wound care and applying a dry dressing to cover and catch any drainage the resident stated no one at the facility had talked to him about infections or the proper way to care for the wound. R#33 said he did not want a dressing on it now. R#33 said, I had training myself and if I wanted a dressing I'd ask for it, but it doesn't need one. When asked where he had training and what kind of training he had, the resident did not answer but informed this surveyor he was done talking about it. Review of Refusal of Treatment policy, on 06/10/19 at 03:55 PM, revealed if the patient refuses treatment staff will determine what the patient is refusing and why. Staff will try to address the patient's concerns and consult his/her supervisor. Notify physician of the refusal of treatment. Staff will determine and document what the patient is refusing; assess the reasons for refusal; advise patient of consequences of refusal; and offer alternative treatments. Document discussions with the patient/health care decision maker, physician, and other involved persons. The wound nurse did not follow the facility's policy on Refusal of Treatment. Review of care plan, on 06/10/19 at 11:23 AM, revealed a focus area related to the potential for further skin breakdown due to history of abscess to right side s/p (status [REDACTED]. An intervention added to this focus area on 06/05/19 by the wound nurse LPN#84 was Resident frequently refuses to come back from room from outside smoking for treatments to be completed A revision noted to the focus area potential for further skin breakdown on 06/06/19 now includes Resident noncompliant with wound treatments at times. The care plan was not revised timely to address resident's noncompliance with wound care treatments. The care plan was not revised to reflect any interventions addressing non-compliance and refusal of care in other areas that LPN#61 confirmed was documented in the resident's medical record. An interview with the Center Nurse Executive (CNE), on 06/10/19 at 2:30 PM, confirmed staff should have notified the physician sooner than 06/05/19, more than forty days after the resident consistently refused wound care treatment. The physician should have been notified when the resident continued refusing wound care treatment, so that the physician could order an alternative treatment if they chose to. The CNE confirmed R#33's care plan should have been revised with interventions concerning refusal of treatment and non-compliance prior to 06/05/19, due to R#33 medical record revealed non-compliance and refusal of care in other areas other than wound treatment.",2020-09-01
26,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2019-06-10,584,D,0,1,8Y4111,". Based on policy review, resident interview, staff interview and record review, the facility failed to ensure the resident has a right to a safe, clean, comfortable and homelike environment. Through a random opportunity for discovery, it was found Resident #23 had a busted up air conditioning unit that was in disrepair. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #23. Facility census: 111. Findings included: a) Resident #23 During initial screening process on 06/02/19 at 2:30 PM, Resident #23's dresser and HVAC (centralized heating ventilation and air conditioning system) unit in her room were found to be in disrepair and maintained in an unsafe manner. The front of the middle wooden dresser drawer was observed to be busted out, loosely hanging off the base of the drawer only to be attached by one nail in the left-hand corner. The Resident's HVAC unit in her room was found to be in poor condition with the plastic framing that enclosed the heating busted in several places, along the top and sides. The HVAC unit was loose and had came unattached from the right-hand side of the heating unit sliding down over the temperature control knob, causing the temperature control knob to be very difficult to turn. On 06/02/19 at 2:33 PM, Resident #23 stated that she could not access her dresser drawers due to the front of the middle drawer falling apart. Resident stated, I told maintenance a while back, and he said he would have to go to into town and get some wood glue to fix the drawer, but he has never come back to fix it. The Resident also stated she had not been able to fully utilize her dresser for quite some time due to the broken dresser drawer, and she was unable to adjust the heat on the HVAC unit due to the broken plastic frame, so she just left it on one setting (high heat) and had gotten used to hot temperature. At 9:05 AM on 06/05/19 during an interview, the Administrator agreed the Resident's dresser drawer was in disrepair and inaccessible to Resident, and it needed repaired immediately. The facility's Administrator stated, I will get with our maintenance guy and have him get whatever supplies he will need to fix it today. In regard to the broken plastic framing around the HVAC unit, the Administrator stated, I will have our maintenance guy go to storage right now and see if we have another HVAC unit that we can use to replace this immediately, this is not acceptable.",2020-09-01
27,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2019-06-10,585,D,0,1,8Y4111,"Based on policy review, Resident interview, staff interview and record review the facility failed to make prompt efforts by the facility to resolve grievances the resident may have. This was true for two (2) of four (4) reviewed in the care area of personal property. Identified Resident's #115 and #82. The facility census was111. Findings included: a) Facility policy Facility Grievance/Concern Policy with a revision date of 03/01/18 stated: --The purpose for grievance /concern reporting is ensure that any patient/patient representative has the right to express a grievance/concern without fear of restraint, interference, coercion, discrimination, or reprisal in any form. --To assure prompt receipt and resolution of the grievance/concern. --Notify the person filling the grievance/concern of resolution within 72 hours. b) Resident #115 During an interview on 06/04/19 at 12:51 PM, Resident #115 stated, that while at the hospital her TV and google home was reported to be missing when she returned, but nothing has been done about it. A review of the Grievance/Concerns reports revealed that there was not a form filled out about the missing items. During an interview on 06/06/19 at 11:30 AM, Administrator was asked about a Grievance/Concern report on this missing TV and Google home. He stated that an employee that is no longer here spoke to Resident # 115, about her missing items, but for whatever reason there was not a form completed. During an interview on 06/10/19 at 9:11 AM, Administrator provided a completed Grievance/ Concern form, dated 06/06/19, he stated that he did look for Resident # 115 missing items and they could not be located. He stated, that the facility will have to replace them. b) Resident #82 During an interview on 06/03/19 at 1:45 PM, Resident #82 stated, that her red satin [NAME]et with a white strip has been missing for a while and that she did tell the Administrator, but nothing has been done. She went on to say, that some of the staff said, that they have looked for it, but all they did was put things in her closet that does not belong to her. During an interview on 06/06/19 at 11:15 AM, Administrator asked Resident #82 about her missing [NAME]et. He said to her that he thought they had found and returned her red [NAME]et. Resident #82 applied to him, that they put a man's tan [NAME]et in her closet, and that was not hers and it is not even red. Administrator looked though her closet with her consent and presents, no red satin [NAME]et was found. On 06/10/19 at 9:11 AM, Administrator provided a Grievance/ Concern form dated; 06/06/19 concerning the red [NAME]et. It stated, that a search for the [NAME]et was done, the item was not located and will be replaced with a like item.",2020-09-01
28,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2019-06-10,656,D,0,1,8Y4111,"Based on observation record review and staff interview, the facility failed to develop a care plan for discharge planning. This was true for one (1) of one (1) reviewed in for the care area of discharge planning. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #117. Facility Census: 111. Findings included: b) Resident #117 A review of the medical record on 06/05/19 for Resident #117 revealed the comprehensive care plan had not been developed to include discharge planning. In an interview on 06/05/19 at 3:22 PM, Social Services Specialist (SSS) #101 verified the care plan for Resident #117 was not developed to include discharge planning.",2020-09-01
29,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2019-06-10,657,D,0,1,8Y4111,"**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 related to refusal of care and non-compliance. This was true of one (1) of one (1) sample residents reviewed for infections (not UTI or Respiratory). This practice had the potential to effect more than a limited number. Resident identifier: #33. Facility census: 111. Findings include: a) Resident #33 During the initial tour of the annual Long-Term Care Survey Process, on 06/03/19 at 11:15 AM, Surveyor# observed Resident (R#33) with dried crusted drainage around a small open circular wound site located on the resident's upper abdominal right side. This was identified as a concern for further investigation by Surveyor# due to the open wound draining and not being covered with a dressing. Review of records, on 06/10/19 at 11:01 AM, revealed R#33's brief interview for mental status (BIMs) score is fourteen (14) indicating the resident is cognitively intact. Pertinent [DIAGNOSES REDACTED]. The resident was admitted to the facility after having incision and drainage (I&D) of abscesses, which developed after having lower-back spinal surgery and after having a cholecystectomy. A cholecystectomy is the surgical procedure to remove a gallbladder. After gallbladder surgery the resident had a drainage tube at the surgical site, on his right upper abdomen, to prevent the build-up of bile, blood, and/or infection. The resident developed an abscess on his right side and another incision and drainage procedure was performed and a drainage tube was again placed to facilitate healing. On 04/04/19, after the drainage tube was removed a new order was given to clean surgical incision to right side with wound cleanser, pat dry, and apply dry dressing every day. Review of the treatment administration record (TAR) revealed daily wound care treatment including a dry dressing was ordered and started on 04/04/19 and on 06/05/19 the wound nurse obtained an order to discontinue treatment due to resident refusing treatment. From the time of the order until the order was discontinued there were sixty-two (62) opportunities to provide daily wound care treatment and it was documented treatment was provided randomly only in the month of April. R#33 received wound care treatment eighteen (18) days due to resident refusing care on the other days, and three (3) times out of the sixty-two (62) opportunities to provide daily wound care treatment there was no documentation either way as to refusal or provision. An interview with the wound nurse, Licensed Practical Nurse (LPN#84), on 06/10/19 at 11:44 AM, revealed LPN#84 said she kept trying to get R#33 to allow her to provide the wound treatment but he always refused. LPN#84 said the resident would let her clean and measure the wound weekly but not provide treatment and place a dry dressing on it daily as it was ordered. This surveyor requested evidence or documentation showing the resident refused wound care treatment. LPN#84 asked the nurse unit manager (LPN#61), to help review R#33's medical records for the requested documentation, while she finished the interview with this surveyor. LPN#84 said she was aware there was still some occasional drainage from the wound site. LPN#84 agreed the physician should have been notified concerning the resident's refusal of daily wound care and dressings. LPN#84 said she thought she contacted the physician sometime during the middle of (MONTH) and told the physician about the resident's refusal of treatment, however she said she did not document the conversation as she should have. When asked what instructions the physician gave her, LPN#84 said, I was to keep encouraging the resident to allow dressing changes. After review of the resident's medical records the nurse unit manager (LPN#61) stated she could find no documentation concerning refusal or non-compliance with the wound care treatment. LPN#61 said there was documentation concerning refusing care and non-compliance in other areas, but nothing concerning wound care. The facility was unable to provide any documentation or evidence that patient education was provided to the resident or any documentation that showed the physician was notified of the resident's refusals of wound care treatment. Review of care plan, on 06/10/19 at 11:23 AM, revealed a focus area related to the potential for further skin breakdown due to history of abscess to right side s/p (status [REDACTED]. An intervention added to this focus area on 06/05/19 by the wound nurse LPN#84 was Resident frequently refuses to come back from room from outside smoking for treatments to be completed A revision noted to the focus area potential for further skin breakdown on 06/06/19 now includes Resident noncompliant with wound treatments at times. The care plan was not revised timely to address resident's ongoing noncompliance with daily wound care treatments. The care plan was not revised to reflect any interventions addressing non-compliance and refusal of care in other areas that LPN#61 confirmed was documented in the resident's medical record. An interview with the Center Nurse Executive (CNE), on 06/10/19 at 2:30 PM, confirmed staff should have notified the physician sooner than 06/05/19, more than forty days after the resident consistently refused wound care treatment. The physician should have been notified when the resident continued refusing daily wound care treatment, so that the physician could order an alternative treatment if they chose to. The CNE confirmed R#33's care plan should have been revised with interventions concerning refusal of treatment and non-compliance prior to 06/05/19, due to the ongoing refusal of daily wound care treatment. The CNE also confirmed based on R#33 medical record showing non-compliance and refusal of care in other areas the care plan should have been revised to address refusal of care in those areas as well.",2020-09-01
30,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2019-06-10,676,D,0,1,8Y4111,"Based on resident interview, staff interview, observation and record review, the facility failed to ensure care and services for the following activities of daily living; Hygiene, bathing, dressing, grooming, and oral care for Resident #33 and #78. This was true for two (2) of two (2) reviewed in the care area of ADLS. Also, the facility failed to provide a communication board for Resident #105. This was true for one (1) of one (1) in the care area of communication. Resident identifiers: #33 and #78. Facility census: 111. Findings included: a) Resident #33 During an interview on 06/03/19 at 10:56 AM, Resident #33 said, that it is hard to get the aides to help him with a shower, they seem to pass him to another aide, and they take a lot of smoke brakes. He stated, that he must give himself a bed bath. When asked how long it had been since his last shower, he stated, that he did not know only that it has been too long. A review of the of the ADL records revealed that Resident #33 is scheduled to get a shower on Wednesdays and Saturdays, and he had no showers or baths for the month of April, and one (1) shower in the month of May. There was 15 days between his last shower until the shower he received on 06/06/19. During an interview on 06/06/19 at 2:35 PM, Unit Manager #61 reviewed the ADL recorded and agreed that Resident #33 did not get his showers as scheduled and she stated, that she had already re-educated three of her staff members. b) Resident #78 During an interview on 06/03/19 at 12:14 PM, Resident #78 complained that it was hard to get a shower, and it had been ever since the one shower has been broken. He stated that the shower had been for down for months. He had below the shoulder length hair that appeared oily. A review of the ADL record revealed Resident #78 was scheduled to have showers on Tuesdays and Fridays. Review of ADL records revealed Resident # 78 in the month of (MONTH) he went 20 days without a shower or bath, and from (MONTH) 24th to (MONTH) the 6th that was 12 days without a shower or bath. During an interview on 06/06/19 at 2:35 PM, Unit Manager #61 reviewed the ADL records and agreed that Resident # 78 did not get his showers as scheduled and she stated, that she had already re-educated three of her staff. c) R105 During an observation with R105 on 06/04/19 at 9:14 AM it was discovered the word/letter board she used as a communication system was found in very poor condition, with food particles, water stains and frayed edges. The regulation requires any communication devices used by residents to be in good repair. In an interview with E84, Licensed Practical Nurse (LPN) on 06/05/19 at 8:44 AM, verified the communication board was in very poor repair and needed to be replaced.",2020-09-01
31,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2019-06-10,684,D,0,1,8Y4111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, resident interview, and policy review, the facility failed to ensure and provide needed care and services in accordance with professional standards of practice for two residents reviewed during the annual LTCSP (Long Term Care Survey Process). This was true for one (1) of one (1) sample residents reviewed for infections (not UTI or Respiratory) who was not provided education on wound care and infection control. This was true for one (1) of five (5) sample residents reviewed for falls that was not provided neuro checks appropriately after a fall. This practice had the potential to affect a limited number. Resident identifier: R#33 and R#60. Facility census: 111. Findings included: a) R#33 During the initial tour of the annual Long-Term Care Survey Process, on 06/03/19 at 11:15 AM, Surveyor# observed Resident (R#33) with dried crusted drainage around a small open circular wound site located on the resident's upper abdominal right side. This was identified as a concern for further investigation by Surveyor# due to the open wound draining and not being covered with a dressing. Review of records, on 06/10/19 at 11:01 AM, revealed R#33's brief interview for mental status (BIMs) score is fourteen (14) indicating the resident is cognitively intact. Some pertinent [DIAGNOSES REDACTED]. The resident was admitted to the facility after having incision and drainage (I&D) of abscesses, which developed after having lower-back spinal surgery and after having a cholecystectomy. A cholecystectomy is the surgical procedure to remove a gallbladder. After gallbladder surgery the resident had a drainage tube at the surgical site, on his right upper abdomen, to prevent the build-up of bile, blood, and/or infection. The resident developed an abscess on his right side and another incision and drainage procedure was performed and a drainage tube was again placed to facilitate healing. On 04/04/19, after the drainage tube was removed a new order was given to clean surgical incision to right side with wound cleanser, pat dry, and apply dry dressing every day. Review of the treatment administration record (TAR) revealed daily wound care treatment including a dry dressing was ordered and started on 04/04/19 and on 06/05/19 the wound nurse obtained an order to discontinue treatment due to resident refusing treatment. From the time of the order until the order was discontinued there were sixty-two (62) opportunities to provide daily wound care treatment and it was documented treatment was provided randomly only in the month of April. R#33 received wound care treatment eighteen (18) days due to resident refusing care on the other days, and three (3) times out of the sixty-two (62) opportunities to provide daily wound care treatment there was no documentation either way as to refusal or provision. An interview with the wound nurse, Licensed Practical Nurse (LPN#84), on 06/10/19 at 11:44 AM, revealed LPN#84 said she kept trying to get R#33 to allow her to provide the wound treatment but he always refused. LPN#84 said the resident would let her clean and measure the wound weekly but not provide treatment and place a dry dressing on it daily as it was ordered. This surveyor requested evidence or documentation showing the resident refused wound care treatment, the physician was notified about the refusals of treatment, and R#33 was provided education concerning the importance of wound care and infection control. LPN#84 asked the nurse unit manager (LPN#61), to help review R#33's medical records for any of the requested documentation, while she finished the interview with this surveyor. LPN#84 said she did not document notifying the physician about the refusal of treatment or any education concerning wound care or infection control. LPN#84 said she was aware there was still some occasional minimal drainage from the wound site. LPN#84 said she thought she contacted the physician sometime during the middle of (MONTH) and told the physician about the resident's refusal of treatment, however she said she did not document the conversation as she should have. When asked what instructions the physician gave her, LPN#84 said, I was to keep encouraging the resident to allow dressing changes. LPN#84 was asked by this surveyor if any other nursing staff tried to get the resident to comply with the ordered wound care treatment, such as the Center Nurse Executive (CNE), formerly known as the Director of Nursing or the Nurse Practitioner (NP). A Nurse Practitioner works in the facility three to four days a week and was available to see the resident. The wound nurse said she did not speak with the CNE or the NP or any other staff concerning R#33's refusals of wound care treatment. LPN#84 said she did not ask anyone else to see or speak to the resident to see if they might get R#33 to comply with the wound care treatment and/or to educate the resident on the importance of proper wound care and/or to ensure the resident understood. After review of the resident's medical records the nurse unit manager (LPN#61) stated she could find no documentation concerning refusal or non-compliance with the wound care treatment or any documentation or evidence that patient education was provided to the resident concerning wound care, disease processes, or infection control. On 06/10/19 at 01:10 PM, interview with the resident revealed the wound still has some occasional drainage, but not as much as it did. When asked if anyone had explained to him the importance of wound care and applying a dry dressing to cover and catch any drainage; the resident stated no one at the facility had talked to him about infections or the proper way to care for the wound. Review of Refusal of Treatment policy, on 06/10/19 at 03:55 PM, revealed if the patient refuses treatment staff will determine what the patient is refusing and why. Staff will try to address the patient's concerns and consult his/her supervisor. Staff will determine and document what the patient is refusing; assess the reasons for refusal; advise patient of consequences of refusal; and offer alternative treatments. Document discussions with the patient/health care decision maker, physician, and other involved persons. The wound nurse did not follow the facility's policy on Refusal of Treatment, particularly advising or educating the resident of consequences of refusal. An interview with the Center Nurse Executive (CNE), on 06/10/19 at 2:30 PM, confirmed the resident should have been provided education by staff regarding wound care, infection control, and disease processes that influence healing, and was not. b) Resident #60 On 06/10/19 at 09:55 AM, medical record review revealed Resident #60 had endured an un-witnessed fall on 05/22/19 at 3:00 PM while transferring from wheelchair to bed. Licensed Practical Nurse (LPN) #110 documented that the Resident stated (typed as written), I hit head but not hurting. At that time, LPN #110 implemented neurological assessments (screening tool used post fall for monitoring and detection of head injury) with a start time of 3:00 PM. The neurological assessments were completed for the following dates and time: --05/22/19 at 3:00 PM --05/22/19 at 3:30 PM --05/22/19 at 4:00 PM --05/22/19 at 4:30 PM --05/22/19 at 5:30 PM --05/22/19 at 6:30 PM --05/22/19 at 7:30 PM --05/22/19 at 8:30 PM --05/23/19 at 12:30 AM --05/23/19 at 4:30 AM The neurological assessment flow sheet was found to be incomplete with no data in all the following categories: level of consciousness, pupil response, hand grasps, movement of extremities, and pain response for nine (9) of the ten (10) assessments completed. The first neurological assessment completed on 05/22/19 at 3:00 PM was the only neurological assessment found to be completed in its entirety. Review of the facility's Neurological policy on 06/10/19 at 11:20 AM revealed the following guidelines for completion of neuroglial assessments (after an unwitnessed fall) to be done at the following frequency: --Every 30 Minutes x 2 hours, then --Every 1 hour x four hours, then --Every four hours x 24 hours. Further review of the neurological assessment sheet revealed the neurological assessments were discontinued without completion for the frequency as indicated. The last neurological assessment was completed on 05/23/19 at 4:30 AM, for a total of ten (10) assessments. In order to complete the neurological assessments for the correct number of times as indicated in the facility's Neurological policy, fourteen (14) assessments should have been done with an end time and date of 05/23/19 at 8:30 PM. During an interview on 06/10/19 at 11:28 AM the Director of Nursing (DON) agreed that the neurological assessments for the Resident was not completed correctly. The DON stated the expectation is for nursing staff to complete all information on the Neurological Assessment Flow sheet, and nothing should ever be left blank. The DON also stated, Yes we stopped the neurological assessments too soon, we did not complete the 24-hour frequency. At 1:10 PM on 06/10/19 during an interview, LPN #110 verified the portion of the Neurological Assessment Flow Sheet that she completed, and agreed the assessments were not completed correctly and should not have been left blank for level of consciousness, pupil response, motor response, and pain response. LPN #110 stated, It just gets so busy around here, and it's hard to get everything done because it's so hectic, I should have done better.",2020-09-01
32,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2019-06-10,689,D,0,1,8Y4111,"Based on observation, staff interview, and Policy review the facility failed to ensure an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This was a random opportunity for discovery with the potential to affect a limited number of residents. Resident identifier: #53. Facility census 111. Findings included: a) Resident #53 1. Policy review Facility Waste Management policy directed personnel to: --Discard contaminated sharps immediately be disposed in a sharp's container. --Not discard sharps in routine trash. 2. Observation During an interview on 06/04/19 at 9:40 AM, with the Resident #53's roommate, this surveyor observed Resident #53 in her wheelchair at the sink with the water running. Resident #53 then moved herself over to the window. Licensed Practical Nurse (LPN) #85 entered the room and asked if she could turn off the water. She turned off the water and picked up a blue razor from the sink and threw it in the trash can under the sink. Resident #53 wheeled herself to the sink and removed the razor from the trash can. With the razor on her lap she wheeled herself back in front of her window and began the shave her left leg. Upon closer observation it was noted that her left ankle was bleeding. 3. Interviews This surveyor asked a passing employee get a nurse and distracted the resident with conversation. LPN #85 returned to the room and looked at Resident #53's left. LPN #85 left the room to retrieve supplies to treat the cuts to Resident #53's legs. There were seven (7) cuts on her left leg from the razor. On 06/04/19 at 10:00 AM, LPN #85 and Nurse Unit Manager (NUM) #61 returned to the room with supplies to treat the wounds. LPN #85 was asked how it Resident #53 had access to a razor. She said she uses the razor for the hairs on her chin, but she does it for her. Resident # 53 stated, that she does not remember where she got the razor from. During an interview with Administrator on 06/06/19 at 11:30 AM, was asked where the razors where kept. He stated they were stored in the clean utility room that had a coded lock on the door, inside the room they were stored in a drawer. He stated, that he does not understand how Resident #53 got a razor. During an interview on 06/10/19 at 10:00 AM, Director of Nursing (DoN) stated, that she has removed all razors from the utility rooms and put them in the medication rooms that are locked and only the nurses have access to and the NA have to sign the razors out and back in with a nurse for disposal. She agreed this was an avoidable accident.",2020-09-01
33,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2019-06-10,690,D,0,1,8Y4111,"Based on observation, staff interview, and policy review the facility failed to ensure a resident's Foley Catheter drainage tubing was securely anchored. This was true of one (1) of three (3) sample residents reviewed for catheter care. This practice had the potential to effect more than a limited number. Resident identifier: R#68. Facility census: 111. Findings include: Observations of Licensed Practical Nurse (LPN#84) providing catheter care to Resident (R#68), on 06/05/19 at 04:13 PM, revealed the Foley catheter drainage tubing was not secured or anchored in anyway. LPN#84 first provided pressure ulcer wound care to R#68 for three (3) different areas on the resident's buttocks prior to providing catheter care. During the provision of care the resident was assisted to turn multiple times from side to side. The Foley catheter drainage tube was not secured to the resident's leg. Observations, during the repositioning of the resident to expose the areas being cared for, revealed strong tension, pulling, and stretching of the drainage tubing was occurring at times. The Foley catheter drainage tube's taut tension, pulling, and stretching had the potential to cause injury to the resident's urethra and urinary meatus. After LPN#84 stated she was finished doing catheter care, this surveyor asked what method the facility used to secure the Foley catheter drainage tube. LPN#84 then acknowledged the resident did not have an anchor device on and should have, and that she also forgot to anchor and secure the tubing when she did the catheter care. LPN#84 confirmed the catheter drainage tubing was supposed to be secured so it did not pull. Review of the facility's Catheter: Indwelling Urinary - Insertion policy revealed #25 stated Ensure the catheter tubing is secured with catheter tube holder or leg strap. Keep the drainage bag below the level of the patient's bladder and off the floor.",2020-09-01
34,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2019-06-10,695,D,0,1,8Y4111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to provide necessary respiratory care and services. This was true for one (1) of two (2) residents reviewed for respiratory services during the investigation phase of the survey process. It was observed R28 was not receiving her oxygen therapy at the prescribed flow rate. Resident identifier: #28. Facility census: 111. Findings included: a) Resident #28 A medical record review for Resident #28 on 06/04/19 revealed a physician's orders [REDACTED]. During an observation on 06/04/19 at 7:56 AM, it was discovered the oxygen concentrator for R28 was administering one and a half (1.5) liters of oxygen via nasal cannula and not the prescribed two (2) liters. Licensed Practical Nurse (LPN) #110 on 06/04/19 at 7:59 AM verified the oxygen concentrator for R28 was set on (1.5) liters and not the prescribed two (2) liters.",2020-09-01
35,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2019-06-10,880,E,0,1,8Y4111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and policy review, the facility failed to ensure and maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infection to the extent possible. This was true for observations made in the laundry room regarding an inadequate negative air pressure. This was true for one (1) of one (1) sample residents reviewed for infections (not UTI or Respiratory) who had an exposed open draining wound. This was true of one (1) of three (3) sample residents reviewed for catheter care where a disposable contaminated wipe was placed back in the package with other uncontaminated disposable wipes. This was true for one (1) of four (4) sample residents reviewed for feeding tubes, who had a soiled feeding tube syringe laying out in the open not bagged. This was true for random observations made on two (2) separate occasions for a resident with a Foley catheter; one (1) observation revealed the Foley catheter drainage bag on the floor and one (1) observation revealed the Foley catheter drainage tubing on the floor. This practice had the potential to effect more than a limited number. Resident identifier: R#33, R#68, and R#23. Facility census: 111. Findings included: a) Laundry Room Inspection of the laundry room on 06/06/19 at 09:26 AM with the Environmental Services Director and the Director of Maintenance revealed the laundry room exhaust fan that provided the negative airflow in the dirty laundry room was not working properly. The Director of Maintenance after inspecting the exhaust fan said the exhaust fan was barely pulling air. The Environmental Services Director and the Director of Maintenance both acknowledged there was not adequate negative air flow in the dirty laundry room due to the poor performance of the exhaust fan. Both the Environmental Services Director and the Director of Maintenance confirmed the inadequate negative air flow in the dirty laundry room created an infection control issue. The Director of Maintenance said he would immediately have the fan fixed. b) R#33 - an open draining wound During the initial tour of the annual Long-Term Care Survey Process, on 06/03/19 at 11:15 AM, Surveyor# observed Resident (R#33) with dried crusted drainage around a small open circular wound site located on the resident's upper abdominal right side. This was identified as a concern for further investigation by Surveyor# due to the open wound draining and not being covered with a dressing. Review of records, on 06/10/19 at 11:01 AM, revealed R#33's brief interview for mental status (BIMs) score is fourteen (14) indicating the resident is cognitively intact. Some pertinent [DIAGNOSES REDACTED]. The resident has a history of having abscesses that have needed to be treated with incision and drainage (I&D) procedures. The resident last abscess was on his right side and on 04/04/19, after the drainage tube was removed a new order was given to clean surgical incision to right side with wound cleanser, pat dry, and apply dry dressing every day. Review of the treatment administration record (TAR) revealed daily wound care treatment including a dry dressing was ordered and started on 04/04/19 and on 06/05/19 the wound nurse obtained an order to discontinue treatment due to resident refusing treatment. From the time of the order until the order was discontinued there were sixty-two (62) opportunities to provide daily wound care treatment and it was documented treatment was provided randomly only in the month of April. R#33 received wound care treatment eighteen (18) days due to resident refusing care on the other days, and three (3) times out of the sixty-two (62) opportunities to provide daily wound care treatment there was no documentation either way as to refusal or provision. An interview with the wound nurse, Licensed Practical Nurse (LPN#84), on 06/10/19 at 11:44 AM, revealed LPN#84 said she kept trying to get R#33 to allow her to provide the wound treatment but he always refused. LPN#84 said the resident would let her clean and measure the wound weekly but not provide treatment and place a dry dressing on it daily as it was ordered. This surveyor requested evidence or documentation showing the resident refused wound care treatment, the physician was notified about the refusals of treatment, and R#33 was provided education concerning the importance of wound care and infection control. The facility was unable to provide any documentation or evidence that patient education was provided to the resident or any documentation that showed the physician was notified of the resident's refusals of wound care treatment untill 06/05/19. LPN#84 said she was aware there was still some occasional drainage from the wound site. LPN#84 agreed the physician should have been notified concerning the resident's refusal of daily wound care and dressings and that the open wound was a breech of infection control principals. On 06/10/19 at 01:10 PM, interview with the resident revealed the wound still has some occasional drainage, but not as much as it did. When asked if anyone had explained to him the importance of wound care and applying a dry dressing to cover and catch any drainage the resident stated no one at the facility had talked to him about infections or the proper way to care for the wound. An interview with the Center Nurse Executive (CNE), on 06/10/19 at 2:30 PM, confirmed staff should have notified the physician sooner than 06/05/19, more than forty days after the resident consistently refused wound care treatment. The physician should have been notified when the resident continued refusing wound care treatment, so that the physician could order an alternative treatment if they chose to. The CNE confirmed an open draining wound is an infection control issue. c) R#68 disposable wipes Observations of Licensed Practical Nurse (LPN#84) providing peri-care (washing the genitals and anal area) and catheter care to Resident (R#68), on 06/05/19 at 04:13 PM, revealed a breech in infection control principals. LPN#84 used packaged disposable wipes to provide the peri-care and to clean around the catheter drainage tube inserted in the resident's urethra. When the LPN finished providing peri-care she took her soiled gloved hand that was contaminated from providing peri-care and pushed a clean unused disposable wipe back into the package, thus contaminating the package of disposable wipes. LPN#84 acknowledge this was a breach in infection control principles. d) Resident #23 On 06/05/19 at 10:50 AM observation was made of a 60 milliliter (ml) syringe in Resident's room lying on her bedside table. The syringe was open to air, placed on top of a pile of papers beside a used tissue. The syringe appeared to be soiled with light brown crusty residue inside the syringe and along the tip. Liscensed Practical Nurse (LPN) #110 verified that syringe belonged to Resident #23, and it had been used for bolus tube feedings. LPN #110 agreed the syringe was not stored properly and discarded syringe into the trash. The syringe did not have any information written on it to indicate the time/date it was initiated for use. Review of facility's Enteral Feeding policy revealed instructions to label and date syringe, store in plastic bag or appropriate container, and the syringe can be used for 24 hours. During an interview on 06/05/19 at 12:30 PM the Director of Nursing (DON) agreed the syringe was maintained in an unsanitary manner. The DON stated, The syringe was improperly stored and should have been dated. Moving forward better measures will be taken. e) R68 On 06/03/18 at 2:01 PM during a random opportunity for discovery a catheter bag belonging to R68 was found on the floor under her bed. During an observation on 06/03/19 at 2:03 PM with E114 assistant center nurse executive (ACNE) verified the catheter bag was on the floor and not securely attached to R68's bed. On 06/04/19 at 12:42 PM during a random opportunity for discovery the catheter tubing was dragging on the floor under R68's wheel chair. During an observation on 06/04/19 at 12:44 PM with E27 nursing assistant (NA) verified the drainage tubing was dragging on the floor and not securely attached under R68's wheelchair. A review of the policy for Care of Indwelling Urinary Catheter revised on 02/01/19 states, Secure catheter tubing to keep the drainage bag .off the floor.",2020-09-01
36,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2018-07-19,684,D,0,1,KVZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff and resident interview, the facility failed to provide appropriate treatment and care in accordance with physician orders [REDACTED]. This affected one (#160) of one sampled resident reviewed as a new admission. The facility census was 113. Findings included: Resident #160 was observed sitting up in bed on 07/16/18 at 10:15 AM. At the time of the observation, Resident #160 was interviewed. He stated he had not received his pain medication when he was admitted to the facility. Resident #160 also stated he did not get all his routine medications in a timely manner. He stated his sister brought in his medications from home and he took those. The medical record review for Resident #160 was completed on 07/19/18 at 5:30 PM. The census tab of the electronic record documented Resident #160 was admitted on [DATE] at 8:13 PM with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. The Medication Administration Record [REDACTED]. The documentation revealed Resident #160 did not receive the aspirin until one day after admission on 07/15/18 at 10:00 PM. The [MEDICATION NAME] was administered three days after admission on 07/18/18 at 6:00 AM. The [MEDICATION NAME] bisulfate was administered two days after admission on 07/16/18 at 9:00 AM. The [MEDICATION NAME] was administered four days after admission on 07/18/18 at 9:00 AM. the Tylenol administered two days after admission on 07/16/18 at 12:15 AM. Review of the weights and vitals summary on 07/19/18 at 5:30 PM revealed Resident #160 had vital signs documented approximately 5 hours after admission on 07/15/18 at 1:12 AM. The second set of vital signs was dated four days later at 07/18/18 at 7:32 PM. There was no documentation of any vital signs taken upon admission. An interview was conducted with the unit manager, Registered Nurse (RN) #23 on 07/18/18 at 6:10 PM. She stated according to the electronic record, Resident #160 was admitted on [DATE] at 8:13 PM. She verified the progress notes did not indicate the date and time Resident #160 was admitted . RN #23 verified Resident #160 did not receive his medications as ordered by the physician according to the Medication Administration Record [REDACTED]. An interview with RN #23 on 07/19/18 at 10:45 AM revealed the expectation of the facility was newly admitted residents received their medications within 24 hours. An interview on 07/19/18 at 12:00 PM with the pharmaceutical technician from the pharmaceutical company revealed Resident #160's medications were delivered within 24 hours on 07/15/18 at 5:34 PM.",2020-09-01
37,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2018-07-19,801,D,0,1,KVZF11,"Based on staff interviews, the facility failed to employ a full-time Dietary Manager that met the qualifications to manage the food and nutrition services. The facility census was 113. Findings included: On 07/18/18 at 5:00 PM, Food Service Director #121 was interviewed. Food Service Director #121 stated he was not a certified dietary manager. He stated he took the position of Food Service Director one week ago. He was not currently enrolled in a program for certification. Food Service Director #121 stated he was told he was going to be enrolled in the training program but did not know when. Food Service Director #121 verified he did not have any nutrition schooling or a college degree in nutrition. He verified he was not a certified food service manager and did not have a national certification for food service management and safety from a national certifying entity. On 07/19/18 at 1:27 PM, Regional Vice President #144 was interviewed. He verified Food Service Director #121 did not meet the qualifications for food service management and was not currently enrolled in a program for certification.",2020-09-01
38,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2018-07-19,812,E,0,1,KVZF11,"Based on observations, staff interview, review of cleaning logs and review of the facility policy, the facility failed to maintain the kitchen environment and equipment in a sanitary manner. This affected one of one kitchen. The facility census was 113. Findings included: On 07/17/18 at 10:57 AM, observations were made in the kitchen with Food Service Director #121. Observations revealed a build-up of food debris on the outside of the cabinet where the hot plate bases were stored. Additionally, a stainless table that holds the toaster had food debris build-up. The lower base cabinets under the prep sink on the back wall of the kitchen had food debris build up. The outside of a warming unit cabinet had a build-up of food debris and the windows around the prep area and prep sink had splatters that looked like food debris. Food Service Director #121 verified the food debris build-up on the hot plate holder cabinet, stainless table, lower base cabinets under the prep sink and the dirty windows. Immediately following the observations on 07/17/18 at approximately 11:00 AM, Food Service Director #121 provided the daily and weekly cleaning logs for (MONTH) (YEAR). The daily and weekly cleaning logs revealed daily and weekly cleaning tasks for the kitchen. The Cleaning Scheduled record revealed no documentation the equipment and work areas including the tables were cleaned by the evening cook assigned to do the task. On 07/11/18, the external plate warmer, bread warmer and work areas, including tables were not documented as being cleaned by the morning cook. On 07/11/18, the weekly cleaning of the base cabinets was not documented as being cleaned by the evening cook. Food Service Director #121 verified documentation of the cleaning was not complete and stated they (the staff) may have just wiped the areas with a rag and sanitizer but did not clean the areas thoroughly to remove the build-up of food debris. Food Service Director #121 was not sure if the cooks had followed the cleaning schedule due to the lack of documentation. Food Service Director #121 verified the food debris buildup on the hot plate holder, tables, cabinets and windows. On 07/19/18 at 1:27 PM, the policy on Cleaning Standards for Food and Nutrition Services revised and dated 06/15/18 was provided by Regional Vice President #144. The policy revealed the purpose was to ensure all food service equipment and areas are clean and sanitary. The process included: Employees utilize the cleaning procedures when completing assigned cleaning duties. Regional Vice President #144 verified the policy was not followed for cleaning equipment of food debris in the kitchen.",2020-09-01
39,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2017-03-01,157,D,0,1,TKXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based resident, staff and physician interviews and clinical record review, the facility failed to notify the physician timely of a resident incident for one resident reviewed. The failed practice had the potential to affect an isolated number of residents. Resident identifiers: #260. Facility census 145. Findings include: a.) Resident #260 Clinical record review, conducted on 02/23/17 at 2:00 p.m., revealed Resident #260 was admitted to the facility on [DATE] after right Achilles tendon repair. The 02/21/17 physician order [REDACTED]. The admission physician orders [REDACTED].>--[MEDICATION NAME] 5-325 milligrams (mg) every six (6) hours as needed for pain --Tylenol 325 mg, 2 tablets every four (4) hours as needed for mild pain. The 02/20/17 admission nursing assessment revealed the resident was not steady moving on and off the toilet and with surface to surface transfer, only able to stabilize with staff assistance. The clinical record was silent regarding any incident involving the resident on 02/22/17 or any administration of as needed pain medication. The record contained no notification of the physician of the incident. During an interview, on 02/23/17 at 12:45 p.m., Resident #260 stated she had an incident in the bathroom the previous evening. The resident stated the nurse aide was in a hurry and did not have the wheelchair close and when she went to get off the toilet. Resident #260 further said, I hit my right foot on the floor. It hurt me. I had to get pain medication for it. I had to have Tylenol and [MEDICATION NAME]. I didn't need it since my first day here. The resident stated her foot was still hurting now. During an interview, on 02/23/17 at 1:58 p.m., LPN #64 stated he was unaware Resident #260 had hurt her foot yesterday evening. LPN #64 stated he would immediately notify the physician about the incident. During an interview, on 02/23/17 at 2:52 p.m., the Director of Nursing (DON) stated she was unaware of the incident regarding Resident #260 until today. The DON expected the staff to have made documentation in the clinical record on the evening shift and reported the incident immediately to the charge nurse, physician and family. The DON stated she was starting an investigation of the incident. During a phone interview, on 02/27/17 at 1:14 p.m., the surgeon stated he expected an immediate assessment of any injury sustained by this resident, and staff would have notified him. The surgeon stated was concerned the resident may have a rupture at the insertion site repair. During an interview, on 02/27/17 at 4:06 p.m., LPN #46 stated she took care of Resident #260 on the evening shift on 02/22/17. LPN #46 stated NA #81 reported to her the resident's foot touched the bathroom floor and did not mention the resident had any pain. LPN #46 stated she did not give the resident any medication for pain, and she did not assess the resident's foot. During an interview, on 02/27/17 at 4:36: p.m., LPN #36 stated she gave Resident #260 two (2) Tylenol about 11:30 p.m. on 02/22/17. LPN #36 verified she did not document she administered the medication. LPN #36 stated she did not assess the resident's foot since it was covered with a sheet. LPN #36 stated the resident reported to her she had hit her right foot on the bathroom floor on the evening shift. During an interview, on 02/28/17 at 10:40 a.m., the DON and Administrator confirmed the lack of timely notification of the physician of a resident incident.",2020-09-01
40,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2017-03-01,164,E,0,1,TKXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to maintain visual privacy during one (1) of three (3) dressing change observations for Resident #177. The facility failed to maintain privacy for medication packages for three (3) residents (Resident #38, #195 and #185). Resident identifiers: #177, #38, #195, and #185. Facility census 145. Findings include: a.) Resident #177 During a dressing change, on 02/23/17 at 12:00 p.m., Registered Nurse (RN) #137 and Licensed Practical Nurse (LPN) #64 entered the room to perform the dressing change. Resident #177 was in the bed by the window. The window blind was open and facing at street level a parking lot. RN #137 nor LPN #64 closed the window blind. RN #137 pulled the privacy curtain part of the way around the foot of the bed but leaving the mirror over the sink exposed to the resident's roommate. LPN #64 instructed Resident #177 to roll over onto her stomach. LPN #64 removed the dressing exposing a large stage IV pressure ulcer on the resident's coccyx. RN #137 was preparing the new dressing items. The resident's roommate face was seen in the mirror. The roommate had two (2) visiting family members. The roommate stated, you can pull the curtain, so she can have her privacy. LPN #64 then pulled the curtain completely to provide privacy from the mirror. During an interview, on 02/23/17 at 1:08 p.m., RN #137 stated she had thought about closing the window blind during the dressing change but just didn't do it. RN #137 stated she didn't realize the privacy curtain had not be pulled completely to provide privacy. During an interview, on 02/23/17 at 3:03 p.m., the Director of Nursing (DON) stated her expectation was all staff were to provide full visual privacy during dressing changes. b) A random observation of the 800 Hall on 02/23/17 at 8:15 a.m. revealed three (3) visible empty medication cards/packets in the trash can of the medication cart. The following medication cards contained the residents full name and medication orders on the pharmacy label: --Resident #38 - [MEDICATION NAME] 200 mg --Resident #195 - [MEDICATION NAME] 30 mg --Resident #185 - Losartan Potassium 50 mg An interview with Registered Nurse-Nurse Manager(RN-NM) #21 on 02/23/17 at 8:15 a.m. revealed the empty medication cards should not have been in the trash. The RN-NM stated once the medication cards are empty they are shredded.",2020-09-01
41,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2017-03-01,272,D,0,1,TKXD11,"Based on staff interview, record review, resident interview, and observation, the facility failed to complete an accurate comprehensive assessment for one (1) of eighteen (18) sample residents. The dental status assessment of one (1) resident was inaccurate on the comprehensive minimum data set (MDS). Resident identifier: #33. Facility census: 145. Findings include: a) Resident #33 During the stage 1 observation and interview of Resident #33 conducted on 02/22/17 at 1:00 p.m., she said she had a broken front tooth and used to wear a partial denture. Her mouth had several teeth in various states of wear and decay, with missing teeth evident. During the medical record review performed on 02/28/17, there were dental consultation notes with the following information: --08/09/16 Exam: Generalized Decay; Generalized Periodontal Disease The attached treatment plan included options for replacing missing teeth, specifically dental implants and partial dentures. --08/30/16 Presents for exam and x ray with extractions Further interview with Resident #33 on 02/28/17 at 10:13 a.m. revealed she was looking into getting a new partial and was awaiting an appointment. On 02/28/17 at 12:30 p.m. a review of the most recent comprehensive (annual) MDS with an assessment reference date (ARD) of 09/24/16 found section L Oral/Dental Status with the following assessment: B. No natural teeth or tooth fragment(s) (edentulous). Registered Nurse Assessment Coordinator #102 was interviewed on 02/28/17 at 1:00 p.m. and said the oral assessment in section L was an error. She provided evidence that a correction was made to the MDS prior to the survey exit.",2020-09-01
42,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2017-03-01,280,D,0,1,TKXD11,"Based on resident interview, medical record review and staff interview, the facility failed to revise a care plan for one (1) of eighteen (18) stage 2 sample residents. The facility did not revise a Brief Interview for Mental Status (BIMS) score. Resident identifier: #12. Facility census 145. Findings include: a) Resident #12 Review of the most recent minimum data set (MDS) with an assessment reference date (ARD) of 12/02/16 revealed a BIMS score of fifteen (15) which indicates the resident is cognitively intact. The residents most recent care plan indicated a BIMS score of five (5) which indicates severely cognitive impaired. On 02/21/17 at 1:00 p.m., Resident #12 was able to answer stage one interview questions without difficulty. During interview on 02/28/17 at 3:45 p.m., registered nurse (RN) #17 stated the BIMS score on the care plan had not been updated from the residents admission and should have been updated to the current BIMS score of 15.",2020-09-01
43,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2017-03-01,323,D,0,1,TKXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record reviews and review of safety data sheets, the facility failed to prevent accidents by failing to use proper transfer technique for 1 of 1 residents reviewed for accidents, resulting in pain. (Resident #260.) The facility failed to prevent accident hazards by storing chemicals safely (Resident #177.)and storing medications safely. Census 145. The findings are: a.) Resident #260 Clinical record review, conducted on 02/23/17 at 2:00 p.m., revealed Resident #260 was admitted to the facility on [DATE] after right Achilles tendon repair. The 02/21/17 physician order [REDACTED]. The admission physician orders [REDACTED].>--Norco 5-325 milligrams (mg) every six (6) hours as needed for pain --Tylenol 325 mg, 2 tablets every four (4) hours as needed for mild pain. The 02/20/17 admission nursing assessment revealed the resident was not steady moving on and off the toilet and with surface to surface transfer, only able to stabilize with staff assistance. The clinical record was silent regarding any incident involving the resident on 02/22/17 or any administration of as needed pain medication. The record contained no notification of the physician of the incident. During an interview, on 02/23/17 at 12:45 p.m., Resident #260 stated she had an incident in the bathroom the previous evening. The resident stated the nurse aide was in a hurry and did not have the wheelchair close and when she went to get off the toilet. Resident #260 further said, I hit my right foot on the floor. It hurt me. I had to get pain medication for it. I had to have Tylenol and Norco. I didn't need it since my first day here. The resident stated her foot was still hurting now. During an interview, on 02/23/17 at 1:58 p.m., LPN #64 stated he was unaware Resident #260 had hurt her foot yesterday evening. LPN #64 stated he would immediately notify the physician about the incident. During an interview, on 02/23/17 at 2:52 p.m., the Director of Nursing (DON) stated she was unaware of the incident regarding Resident #260 until today. The DON expected the staff to have made documentation in the clinical record on the evening shift and reported the incident immediately to the charge nurse, physician and family. The DON stated she was starting an investigation of the incident. During a phone interview, on 02/27/17 at 1:14 p.m., the surgeon stated he expected an immediate assessment of any injury sustained by this resident, and staff would have notified him. The surgeon stated was concerned the resident may have a rupture at the insertion site repair. During an interview, on 02/27/17 at 4:06 p.m., LPN #46 stated she took care of Resident #260 on the evening shift on 02/22/17. LPN #46 stated NA #81 reported to her the resident's foot touched the bathroom floor and did not mention the resident had any pain. LPN #46 stated she did not give the resident any medication for pain, and she did not assess the resident's foot. During an interview, on 02/27/17 at 4:36: p.m., LPN #36 stated she gave Resident #260 two (2) Tylenol about 11:30 p.m. on 02/22/17. LPN #36 verified she did not document she administered the medication. LPN #36 stated she did not assess the resident's foot since it was covered with a sheet. LPN #36 stated the resident reported to her she had hit her right foot on the bathroom floor on the evening shift. During an interview, on 02/28/17 at 7:07 a.m., NA #81 stated she assisted the resident to the bathroom about 8:30 to 9:30 p.m. NA #81 stated the resident got unsteady when getting off the toilet. NA #81 stated, I grabbed her by the waist and sat her back into the wheelchair. The resident hit her foot on the floor. NA #81 stated the resident asked for pain medication because her foot hurt. NA #81 stated she was supposed to use a gait belt to transfer the resident but did not use it. NA #81 stated some resident's just don't like them. During a phone interview, on 02/28/17 at 10:24 a.m., RN #121 stated she worked the night shift on 02/22/17 at 11:00 p.m. until 02/23/17 at 7:00 a.m. RN #121 stated she was unaware of any incident occurring with Resident #260 on the evening shift. RN #121 stated the resident request pain medication at 1:30 a.m. and she gave the resident Norco for her pain. RN #121 stated she did not document the medication administration in the clinical record. RN #121 stated she just got busy and forgot to document the administration of the administration of the administration. During an interview, on 02/28/17 at 10:40 a.m., the Director of Nursing and Administrator confirmed the lack of timely notification of the physician of a resident incident, the lack of timely assessment of resident injury and administration of medication for pain, the lack of following physician orders [REDACTED]. b.) Resident #177 After completion of a dressing change, on 02/23/17 at 12:00 p.m., RN #137 placed an open bottle of 0.25% acetic acid on the resident's window sill above the resident's heater. During an interview, on 02/23/17 at 1:03 p.m., RN #137 stated she left the acetic acid on the window sill, so other staff could have access to it. I didn't want to put it back in the treatment cart. I thought that would be more of an issue. After the interview, RN #137 removed the acetic acid from the window sill and put it in the locked treatment cart. Review of safety data sheet for acetic acid stated solution is corrosive, Causes severe skin burns, eye damage, may be harmful if swallowed, is flammable and to keep away from heat/sparks/open flames/hot surfaces. c) Medications A random observation of the 200 Hall on 02/23/17 at 7:50 a.m., revealed medications on the counter of the nurses's station unattended and accessible to anyone from 7:50 a.m. to 8:00 a.m. The following Resident's medications were observed on the nurses's station counter: --Resident #15 - Ipratropium/Albuterol (3 packs) --Resident #92 - Phenytoin EX 100 mg (56 capsules) --Resident #184 - Clonidine HCL 0.1 mg (56 tablets) --Resident #187 - Celecoxib 200 mg (56 capsules) An interview with Licensed Practical Nurse (LPN) #64 on 02/23/17 at 8:00 a.m. revealed the night shift nurse must have left the medications at the nurse's station. The LPN stated his shift began at 7:00 a.m. The LPN stated the medications should have been locked upon acceptance from the pharmacy. A random observation of the 800 Hall on 02/23/17 at 8:05 a.m. revealed the medication cart was unlocked at the nurses station. The cart was unlocked, unattended, and out of sight of any staff from 8:05 a.m. until 8:12 a.m. The cart contained the medications for all the 800 Hall residents. An interview with Registered Nurse-Nurse Manager (RN-NM) #21 on 02/23/17 at 8:12 a.m. revealed the medication cart should always be locked when not in sight of the nurse.",2020-09-01
44,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2017-03-01,371,E,0,1,TKXD11,"Based on observations, staff interview and review of FDA food code, the facility failed to serve foods in a sanitary manner. One (1) dietary aide was serving food with polished nails without wearing gloves and one dietary aide was wearing rings with stones on each hand while serving food. This has the potential to more than an isolated number of residents. Facility census: 145. Findings included: On 02/28/17 at 12:15 p.m., Dietary Aide (DA) #132 was plating resident food. DA #132 had polished finger nails and was not wearing gloves. DA #132 stated her nails were natural and were polished. Additionally, on 02/28/17 at 12:15 p.m., DA #26 was plating resident food on resident trays. DA #26 was wearing a diamond like ring on her left ring finger and a pearl like ring on her right ring finger. DA #26 stated she usually wore the rings when working in the kitchen. The Dietary Supervisor #125 instructed DA #26 to remove her rings. DA #26 removed her rings. The Dietary Supervisor instructed DA #132 to put on gloves, which she did. Review of the 2013 FDA Food Code Chapter 2 page 50 states: Unless wearing intact gloves in good repair, a FOOD EMPLOYEE may not wear fingernail polish or artificial fingernails when working with exposed FOOD. Except for a plain ring such as a wedding band, while preparing FOOD, FOOD EMPLOYEES may not wear jewelry including medical information jewelry on their arms and hands.",2020-09-01
45,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2017-03-01,431,E,0,1,TKXD11,"Based on observation and staff interview, the facility failed to properly store medications. The facility did not ensure resident's medications delivered from the pharmacy were put away in a inaccessible and locked area and did not ensure a medication cart on the 800 Hall was locked. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #15, #92, #184, and #187. Facility census: 145. Findings include: a) A random observation of the 200 Hall on 02/23/17 at 7:50 a.m. revealed medications on the counter of the nurses's station unattended and accessible to anyone from 7:50 a.m. to 8:00 a.m. The following Resident's medications were observed on the nurses's station counter: --Resident #15 - Ipratropium/Albuterol (3 packs). --Resident #92 - Phenytoin EX 100 mg (56 capsules). --Resident #184 - Clonidine HCL 0.1 mg (56 tablets). --Resident #187 - Celecoxib 200 mg (56 capsules). An interview with Licensed Practical Nurse (LPN) #64 on 02/23/17 at 8:00 a.m., revealed the night shift nurse must have left the medications at the nurse's station. The LPN stated his shift began at 7:00 a.m. The LPN stated the medications should have been locked upon acceptance from the pharmacy. b) A random observation of the 800 Hall on 02/23/17 at 8:05 a.m., revealed the medication cart was unlocked at the nurses station. The cart was unlocked, unattended, and out of sight of any staff from 8:05 a.m. until 8:12 a.m. The cart contained the medications for the 800 Hall residents. An interview with Registered Nurse-Nurse Manager (RN-NM) #21 on 02/23/17 at 8:12 a.m., revealed the medication cart should always be locked when not in sight of the nurse.",2020-09-01
46,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2017-03-01,441,D,0,1,TKXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to follow proper hand hygiene techniques during medication administration for one (1) of twenty six (26) opportunities observed. In addition, the facility failed to perform proper cleaning technique on reusable equipment during one (1) of three (3) dressing change observations. This failed practice affected an isolated number of residents who received medications administered by the facility and of those who had pressure ulcers. Resident identifiers: #126 and #177. Facility census: 145. Findings include: a) Resident #126 An observation of medication administration on 02/28/17 at 08:24 a.m., revealed Licensed Practical Nurse (LPN) #44 attempted to pop a [MEDICATION NAME] 25 milligram (mg) tablet out of the packaging into a medicine cup for Resident #126. The pill missed the cup and fell to the floor. LPN #44 picked up the pill with her bare hands and discarded it. She then popped out a second [MEDICATION NAME] 25 mg tablet into the medication cup and continued with her medication administration for Resident #126 without washing or sanitizing her hands. On 02/28/17 at 10:59 a.m. this matter was discussed with Employee #4, who was responsible for infection control. She agreed that it was an infection control issue. She provided the facility policy titled Handwashing/Hand Hygiene last revised (MONTH) (YEAR). This policy stated to use alcohol-based hand rub or soap and water Before preparing or handling medications. b.) Resident #177 During a dressing change, on 02/23/17 at 12:00 p.m., RN #137 removed scissors from her uniform pocket and cut kling soaked with acetic acid which LPN #64 was using to pack resident #177 coccyx stage IV wound. RN #137 did not clean the scissors prior to use. At the end of the dressing change procedure, RN #137 placed the scissors back into her uniform pocket without cleaning them when she left the room. During an interview, on 2/23/17 at 1:08 pm, RN #137 stated she probably should have cleaned her scissors prior to use and after use. During an interview, on 2/23/17 at 3:03 pm, the Director of Nursing confirmed RN #137 should have cleaned the scissors before and after use during the dressing change.",2020-09-01
47,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2017-03-01,514,D,0,1,TKXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain a medical record that was complete and accurately for two (2) of eighteen (18) sample residents. Behavior monitoring and bowel pattern tracking was not consistently and/or accurately documented for one (1) resident and a second resident had incomplete medication administration records. Resident identifiers: #258 and #260. Facility census: 145. Findings include: a) Resident #258 1. Behavior sheets A medical record review for Resident #258 on 02/27/17 revealed she had physician's orders [REDACTED]. This medication was first administered on 02/03/17 at 8:00 p.m. She also had an order for [REDACTED]. Although the orders were initiated on 02/03/17, the Behavior/Intervention Monthly Flow Sheet were not documented until night shift of 02/04/17 for both [MEDICATION NAME] and [MEDICATION NAME]. In addition, there were multiple blanks holes on both sheets. The director of nursing (DON) was interviewed on 02/27/17 at 4:39 p.m. and she acknowledged the holes on the sheets were where nursing had not completed the forms. 2. Bowel patterns During the medical record review for Resident #258 on 02/27/17, there were several missing entries in the nurse aide documentation for Bowel Patterns. In addition, the documentation reflected no record of the resident having a bowel movement from night shift on 02/17/17 until evening shift on 02/23/17, as the nurse aides had documented 0 meaning No Bowel Movement. Nurse manager #21 was interviewed on 02/28/17 at 3:05 p.m. and she said that the documentation was inaccurate. She also agreed that the holes in the record resulted in the record being incomplete. c.) Resident #260 Clinical record review, conducted on 02/23/17 at 2:00 p.m., revealed Resident #260 was admitted to the facility on [DATE] after right Achilles tendon repair. The 02/21/17 physician order [REDACTED]. The admission physician orders [REDACTED].>--[MEDICATION NAME] 5-325 milligrams (mg) every six (6) hours as needed for pain --Tylenol 325 mg, 2 tablets every four (4) hours as needed for mild pain. The 02/20/17 admission nursing assessment revealed the resident was not steady moving on and off the toilet and with surface to surface transfer, only able to stabilize with staff assistance. The clinical record was silent regarding any incident involving the resident on 02/22/17 or any administration of as needed pain medication. The record contained no notification of the physician of the incident. During an interview, on 02/23/17 at 12:45 p.m., Resident #260 stated she had an incident in the bathroom the previous evening. The resident stated the nurse aide was in a hurry and did not have the wheelchair close and when she went to get off the toilet. Resident #260 further said, I hit my right foot on the floor. It hurt me. I had to get pain medication for it. I had to have Tylenol and [MEDICATION NAME]. I didn't need it since my first day here. The resident stated her foot was still hurting now. During an interview, on 02/27/17 at 4:36: p.m., LPN #36 stated she gave Resident #260 two (2) Tylenol about 11:30 p.m. on 02/22/17. LPN #36 verified she did not document she administered the medication. LPN #36 stated she did not assess the resident's foot since it was covered with a sheet. LPN #36 stated the resident reported to her she had hit her right foot on the bathroom floor on the evening shift. During a phone interview, on 02/28/17 at 10:24 a.m., RN #121 stated she worked the night shift on 02/22/17 from 11:00 p.m. until 02/23/17 at 7:00 a.m. RN #121 stated she was unaware of any incident occurring with Resident #260 on the evening shift. RN #121 stated the resident request pain medication at 1:30 am and she gave the resident [MEDICATION NAME] for her pain. RN #121 stated she did not document the medication administration in the clinical record. RN #121 stated she just got busy and forgot to document the administration of the medication. During an interview, on 02/28/17 at 10:40 a.m., the Director of Nursing and Administrator confirmed the lack of complete and accurate documentation in the clinical record.",2020-09-01
48,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2018-05-03,561,D,0,1,X20F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to promote one resident's right to make choices about aspects of their life. Specifically, the facility failed to provide a shower to resident #305 as requested. This failed practice had the potential to affect a limited number of residents. Resident identifier: #305. Facility census: 142. Findings included: a) Resident #305 According to the 5/18 physician's orders [REDACTED]. According to the admission progress note, dated 4/28/18, the resident was oriented to person, place, and time and was able to make her needs known. In an interview on 4/30/18 at 4:12 PM, Resident #305 said she had just admitted that past Saturday. She said the hospital never showered her so she really wanted a shower. She wanted to feel clean and thought she would feel much better after she received a shower. She said she had been asking for a shower since she admitted to the facilty. She asked her aide taking care of her that day if she could get a shower and the aide told her she would see what she could do. The resident was tearful during the interview. In an interview on 5/1/18 at 5:03 PM, Resident #305's hair was visibly wet and she was brushing it. She said she had just received a shower, her first since admission, and she felt much better. The resident's 5/18 physician's orders [REDACTED]. An order dated 4/28/18 directed Transfer assist of 2 with gait belt. An order dated 4/30/18 directed Cont (continue) with transfer assist of 2 and gait belt. Pt (patient) non-ambulatory on wing. Shower documentation and progress notes were reviewed on 5/2/18 at 4:50 PM. The shower records revealed an entry on 5/1/18 that documented not applicable, indicating a shower was not provided. Review of the progress notes revealed there was no documentation that a shower was given. The skilled progress note on 4/29/18 indicated the resident required assistance of two with transfers and bed mobility. In an interview on 5/2/18 at 4:31 PM, Licensed Practical Nurse (LPN) #34 said she was the one who admitted the resident after dinner on Saturday night. On admission the resident expressed that the hospital had not showered her in four days or changed her gown, so they had discussed getting her a shower. On Saturday night, staff provided her a bed bath and got her cleaned up. The resident was supposed to receive a shower on Sunday if she still expressed the desire to receive one. LPN #34 said the shower schedule was pre-set based on room numbers. The resident's shower days were Tuesdays and Fridays. She said no showers were scheduled on Sundays, but staff should have provided one, if needed. In an interview on 5/2/18 at 5:10 PM, CNA #121 said she had only worked at the facility for a few weeks and had worked that past Sunday. She said Resident #305 had requested a shower on Sunday, but she did not provide her with one. She explained she thought therapy had to evaluate a new resident before staff could assist the resident in any transfers. She said the resident stayed in bed all day on Sunday as she would not get residents up until therapy evaluated them. She stated she provided the resident with a shower 5/1/18, Tuesday. The Assistant Director of Nursing was present during the interview with CNA #121. She said the resident could have received a shower on Sunday as she requested. She said the facility's protocol was that all new admissions could be transferred with two staff and a gait belt until therapy could evaluate them, or if orders indicated otherwise. In an interview on 5/3/18 at 11:45 AM, the Director of Nursing (DON) said the CNA should have spoken to the nurse about the resident's transfer status. The nurse could have called the doctor to obtain orders, if they were unclear. She said most new admissions were a two assist with a gait belt unless they were walking as they entered the facility or they had non-weight bearing orders. She said residents could receive showers whenever they requested them. There was a shower schedule but if a resident requested a shower, then the staff should provide one.",2020-09-01
49,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2018-05-03,582,E,0,1,X20F11,"Based on interview and record review, the facility failed to issue liability and appeal notices as required. Specifically, the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) letter to Resident #253, issued the incorrect Center for Medicare and Medicaid Services (CMS) form letter to Resident #254 and issued an inaccurately completed SNFABN form letter and an altered NOMNC form letter to Resident #144. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #253, #254, and #144. Facility census: 142. Findings included: a) Review of guidelines Review of the current guidelines for the Centers for Medicare and Medicaid Services instructions for the SNFABN letters of notice, revised 1/18, revealed .Medicare requires SNFs (skilled nursing facilities) to issue the SNFABN (Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage) to original Medicare, also called fee-for-service, beneficiaries, prior to providing care that Medicare usually covers . The SNFABN has the following 5 (five) sections for completion: Header, Body, Option Boxes, Additional Information, Signature and Date . SNFs must enter the first and last name of the beneficiary receiving the notice . There are 3 (three) options listed on the SNFABN with corresponding check boxes. The beneficiary must check only one option box . Review of the current guidelines for the CMS instructions for the NOMNC letter of notice revealed, .The NOMNC (Notice of Medicare Non-Coverage) must be delivered at least two calendar days before Medicare covered services end . The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice . b) Resident #253 Review of the clinical record for Resident #253 revealed no SNFABN letter was issued when Medicare benefits ended. c) Resident #254 Review of the clinical record for Resident #254 revealed the SNFABN letter was issued on 1/3/18 and signed, however the form letter was not the correct CMS required form letter. Resident #254 was issued an older version of the SNFABN form letter (CMS R-131) instead of the correct and current form (CMS- ). In addition, the required sections were not completed. d) Resident #144 Review of the clinical record for Resident #144 revealed the SNFABN letter was issued on 4/19/18 and signed, however the form section for Reason Medicare (MONTH) Not Pay, was inaccurately completed according to the CMS instructions. The NOMNC letter was issued on 4/19/18, however was altered from its original form according to the CMS instructions. Page 1 of the NOMNC form ran over onto page 2. e) Staff interviews An interview with the Administrator and the Director of Nursing on 5/3/18 at 11:30 AM revealed they were unaware the SNFABN and NOMNC form letters were not being issued regularly or being completed accurately according to the CMS instruction sheets. The Administrator and the Director of Nursing stated they would refer to the most current CMS instruction sheets for further education. The Administrator stated she felt the missing SNFABN for Resident #253 was an isolated situation and stated she felt the facility had issued the resident a letter but could not provide proof of the issued letter.",2020-09-01
50,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2018-05-03,657,D,0,1,X20F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to include the resident in the care planning process. Specifically, the facility failed to keep one resident (#108) reviewed for Discharge informed of his progress towards discharge. This failed practice had the potential to affect a limited number of residents. Resident identifier: #108. Facility census: 142. Findings included: a) Facility policy The care planning policy, revised 09/2013, was reviewed on 5/3/18 at 9:15 AM. The policy indicated in pertinent part: .The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan . Every effort will be made to schedule care plan meeting at the best time of the day for the resident and family .' b) Resident #108 Resident #108 admitted to the facility on [DATE] and discharged to the community on 4/30/18. According to admission physician's orders [REDACTED]. Review of the 3/22/18 Minimum Data Set (MDS) assessment on 5/2/18 at 11:35 AM. According to the MDS, the resident was cognitively intact with a brief interview of mental status score of 15 out of 15. The MDS assessed he required extensive assistance with all activities of daily living (ADLs). In an interview on 4/30/18 at 1:13 PM, the resident stated he was scheduled to be discharged around 3:00 PM that day. He complained that there was a lack of communication between the facility and himself. He stated he received therapy under his insurance and that staff never discussed his progress with him or discussed when discharge may occur. He said, all of a sudden they came and spoke with him and said they were discharging him in a couple days. He said he appealed the discharge and won, but he did not want to stay at the facility due to the lack of communication. He said they had a meeting with him when he first arrived back in March, but no other meetings since then. He said the staff had an internal meeting every week to discuss residents, but no one ever came and spoke to him about what was talked about in that meeting regarding his care or progress. The resident's record was reviewed on 5/2/18 at 1:15 PM. The discharge care plan, initiated on 3/15/18, identified the resident expressed his wish to discharge home with family. Interventions included reviewing progress towards discharge during scheduled meetings. Review of progress notes revealed no documented conversations with the resident regarding his progress or plans towards discharge. There was no evidence of care conferences that took place during his stay. A Social Services note, dated 3/15/18, revealed the Social Service staff met with the resident, completed the admission packet with him and spoke with his family member by phone. They discussed options in case the resident would be unable to return home. The plan was for the resident to return home with family. Social Services made them aware of their services and assistance. Social Services documented the internal Medicare meeting that occurred each week. The Medicare meeting note dated 4/25/18 revealed the resident's last covered day would be 5/4/18 with long term care being recommended. There was no documentation after the meeting indicating the resident was informed of the upcoming end of therapy. On 4/27/18, Staff #70 documented in the record that she issued the notice of Medicare non coverage to the resident. The notice was discussed with the resident's family member via phone. She discussed the appeal process with both of them. There was no explanation for the 2 day delay between when the facility determined the resident's therapy would end and when the resident was notified. On 4/30/18, Social Services documented the resident was discharging from the facility and which services would be provided at home. A note from the nurse practitioner on 4/30/18 documented in pertinent part, .At this time patient feels he is being thrown out. Discussed situation and insurance and he would continue therapy at home . The Physical Therapy and Occupational Therapy daily progress notes were reviewed on 5/3/18 at 11:20 AM. Review of the notes revealed there was no documentation from therapy discussing the resident's progress with the resident or progress towards discharge. On 4/27/18, the same date the resident was notified his therapy was ending, Physical Therapy documented, Therapist met with patient and spouse and discussed patients D/C (discharge) planning. Educated patient on his progress with therapy to this point and discussed patients future progress and plans. In an interview on 5/2/18 at 1:27 PM, Social Services #51 explained one of the two Social Service staff met with residents within 48 hours of admission. They provided the resident with a packet of information, discussed their history and goals, and the discharge planning process. She said they had an open door policy so if any one wanted to speak to them, they were able to. Social services helped arrange for home services and placements. She said she met with residents regularly to complete MDS assessments. She said the facility had internal Medicare meetings every Wednesday morning. She tried to meet with the residents after that meeting, but mostly met with those that had upcoming discharge date s or that were going to need increased services. She said she always tried to document in the record whenever she had a conversation with a resident or family member. She remembered speaking with Resident #108's family member more than the resident. She stated the family member called every couple weeks to find out what the resident was going to need when he returned home. She further explained when she met with a resident upon admission she told them that they could have a care conference any time they wanted to. She said the short-term residents did not have a set care conference schedule and that the resident, family, or therapy were the ones to typically initiate the scheduling of a care conference. She said the facility did not complete an admission care conference. In an interview on 5/2/18 at 5:33 PM Case Manager #70 said she was the case manager for the residents that had managed care. She helped with discharge planning along with social services. She remembered having a conversation with the resident when she issued his notice of Medicare non-coverage. She explained that he was being discharged by his insurance. She said it was hard to let the resident know when they may be discharged because insurance could cut them off at any time. The interim therapy director was interviewed on 5/3/18 at 10:34 AM. She said therapy discussed progress on a daily basis with residents during their sessions. Those conversations would be documented in their progress notes. She said therapy did not attend care conferences unless they were the ones to request the care conference. Normally a care conference was suggested when the discharge was questionable, which would be if the resident needed placement instead of returning home. She stated she worked directly with Resident #108 and remembered having conversations with the resident about his progress. She remembered speaking with the resident's family member a couple of times as well. She said she was not sure why no care conference was held, but the resident got mad at therapy because they were discharging him. In an interview on 5/3/18 at 11:40 AM, the interim therapy director reviewed the weekly progress notes. She confirmed there was no documentation to indicate the resident was spoken to about his progress towards discharge. She was certain that conversations occurred but could not find any evidence of the conversations. In an interview on 5/3/18 at 12:35 PM the Administrator said the facility met internally every week to discuss short term stay residents. Social Services communicates with the residents and gets the discharge information from the resident, such as their prior level of function and home setting upon admission. Therapy speaks to residents from the beginning as well about discharge planning and how the process worked. She said care conferences should be completed prior to the resident being discharged and therapy would be at that meeting.",2020-09-01
52,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2018-05-03,698,D,0,1,X20F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate care with the [MEDICAL TREATMENT] Center for Resident #126, one of one residents reviewed for [MEDICAL TREATMENT]. The facility failed to ensure communication from the [MEDICAL TREATMENT] Center following the resident's treatment was reviewed and recorded. This failed practice had the potential to affect a limited number of residents. Resident identifier: #126. Facility census: 142. Findings included: a) Resident #126 Review of the resident's record revealed Resident #126 was admitted to the hospital 4/16-21/18. She readmitted to the facility 4/21/18. Review of physician's orders [REDACTED]. The record revealed the resident refused [MEDICAL TREATMENT] on 4/24/18, but went on 4/28/18 and 5/1/18. physician's orders [REDACTED]. Staff were directed, in the order, to put results in computer. Review of the electronic record revealed one weight for 4/28/18 and no weights for 5/1/18. In addition, a dietary progress note, dated 5/2/18 indicated .Current [MEDICAL TREATMENT] labs are unavailable to me here at this time. The [MEDICAL TREATMENT] labs were recommended to be obtained by our facility at today's morning/clinical meeting. In an interview on 5/2/18 at 1:34 PM, Licensed Nurse #82 was asked how the [MEDICAL TREATMENT] center and the facility communicate. She explained she did not work the floor very often, but had been pulled to do so that day. She stated they used to have a little form, with pre and post weights. Vital signs. She looked through the resident's record but was unable to locate any communication. In an interview on 5/2/18 at 1:37 PM, the Assistant Director of Nursing #88, stated We have a little form, with weights, treatment changes. Might be in her packet. Probably downstairs with (Receptionist). Let me go check. At 5/2/18 at 1:51 PM Staff #33 provided a blank copy of the [MEDICAL TREATMENT] Patient Data Sheet. It goes in the envelope and the van driver takes it to [MEDICAL TREATMENT], then they fill it out, bring it back. I don't know what happens then, I guess the nurse puts it in the computer? This resident went to the hospital. I wonder if we didn't make her a packet (to send to [MEDICAL TREATMENT]) when she got back? I will go do that. At 5/2/18 at 2:00 PM, ADON #88 stated she asked the transportation driver what he did with the papers he brought back from the [MEDICAL TREATMENT] Center. She said he left the envelope in the resident's room after each appointment. ADON #88 located the 4/28 and 5/1/18 [MEDICAL TREATMENT] Patient Data Sheets in the resident's room. She stated the nurse should have obtained and reviewed them and put them in the chart. She explained if medication orders changed or something significant occurred at [MEDICAL TREATMENT], the center would usually call and notify the facility. However, the [MEDICAL TREATMENT] Center recorded vital signs, weights, lab results and other communication on the forms and the facility should still be obtaining these.",2020-09-01
55,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2018-05-03,812,D,0,1,X20F11,"Based on observation, interview and record review, the facility failed to store, prepare and serve food in accordance with professional standards for food service safety in one of one kitchens. Specifically, the facility failed to ensure staff conducted proper hand hygiene and transported clean utensils in a sanitary manner. This failed practice had the potential to affect a limited number of residents. Facility census: 142. Findings included: a) Facility policy The Safety and Sanitation policy, revised 12/14/17, was provided by the Director of Nursing on 5/3/18 at 1:20 PM. The policy directed, in pertinent part: VII. Hand washing . 1. When to wash: i. After working with or cleaning dirty equipment or utensils . l. Between glove changes . q. Between any dirty to clean task . VII. Glove use . 1. Single use gloves: c. Wash hands thoroughly before and after wearing or changing gloves. Bacteria will build up under gloves and should be washed away after wearing gloves . 3. Cloth gloves: a. (MONTH) not be used in direct contact with food . b) Observations On 4/30/18 at 8:40 AM, during the initial tour, two trash cans were observed close to the handwashing sink. One trash can had a foot pedal that opened the top. The other trash can had a lid on top that had to be manually opened. Multiple observations were made on 5/1/18 from 11:10 AM to 12:25 PM. At 11:30 AM, Cook #119 was observed to mix cabbage and noodles togethers. During this process, the food mixture touched her oven mitt that was holding onto the pan. At 11:37 AM, Cook #119 was observed to gather the serving utensils to serve from the steam table. While transporting the utensils to the steam table, she held the ladle for the gravy up next to her chest, touching her shirt. Her shirt was visibly dirty with food debris. At 11:45 AM, Dietary Staff #89 was observed spreading butter on slices of bread, while wearing gloves. When she was finished with the butter, she covered it with plastic wrap and pulled a pen out of her shirt to write the date. Wearing the same gloves, she proceeded to place the buttered bread in a pan and grab slices of cheese to make grilled cheeses. Cook #119 served the lunch meal from the steam table. Multiple observations were made during the lunch service from 11:54 AM to 12:25 PM. While Cook #119 served, she was observed to place two to three plates along the steam table. She then leaned across the plates to get food from the back of the steam table. As she did this, her shirt touched the plates. This process was observed several times. From 11:10 AM to 12:25 PM, multiple observations were made of staff changing their gloves without washing their hands between glove changes. Food preparation was observed on 5/2/18 from 10:00 AM to 10:30 AM. At 10:02 AM, Cook #119 was observed to leave the kitchen with a measuring cup full of butter. She was observed to use the microwave in the staff break room. She came back into the kitchen at 10:05 AM and the butter was melted. She did not wash her hands when she returned to the kitchen. She proceeded to prepare the pureed foods and used the butter for the vegetables. At 10:09 AM, after Cook #119 made a batch of pureed vegetables in the food processor, the blade fell out as she poured the mixture into the pan. She touched the blade, rinsed it off under some water, and then placed it back into the processor. She proceeded to make other portions of pureed vegetables. At 10:18 AM, Cook #119 was observed to dry off her hands and place the paper towel in the trash can with the manual lid on top of it. She had to touch the trash can lid to place the paper towel inside. Cook #119 stated that the trash can with the manual lid was the trash can they used for everything, including after they washed their hands. She said the trash can with the pedal was used for salad preparation. At 10:24 AM, Cook #119 grabbed the food processor pieces and spatula that had been sanitized in the three-compartment sink. While transporting the food processor pieces and spatula to the preparation area, she held the pieces up against her shirt. Her shirt was visibly soiled with food debris. From 10:00 AM to 10:30 PM, multiple observations were made of staff changing their gloves without washing their hands between glove changes. c) Interviews In an interview on 5/3/18 at 10:08 AM the Dietary Manager stated every time a staff member changed gloves, they were supposed to wash their hands. Staff were also supposed to wash their hands each time they entered the kitchen. If they left to go to the breakroom, then they needed to wash their hands when they returned. She stated she did not know why there was not a microwave in the kitchen but said staff should not have to go to the break room to use the microwave for food preparation. She said when transporting clean utensils, they should be carried away from the body. If the utensils touched the body, such as a shirt, then that was unsanitary. Clothing was not supposed to touch plates as meals were being served from the steam table.",2020-09-01
56,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2018-05-03,842,D,0,1,X20F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately transcribe, in the medical record, the correct amount of nutritional supplement ordered for one of five residents reviewed for nutritional weight loss. Resident identifier: #98. Facility census: 142. Findings included: a) Resident #98 The medical record was reviewed on 5/2/18 at 11:45 AM. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident had verbal behaviors, received diuretics and had depression and anxiety. The Plan of Care dated 3/26/18 for Nutritional Status as evidenced by significant weight loss revealed the goal for the resident to consume appropriate amounts of food and fluids to maintain nutritional status. The plan of care revealed interventions to maintain weight through the next review that included the following: assist as needed to consume foods and/or supplements and fluids offered at and between meals, provide supplements per orders: Med Pass 2.0 (Dietary Supplement) 3 ounces, 4 times per day. On 5/2/18 at 1:54 PM the Medication Administration Records (MAR) for (MONTH) and (MONTH) (YEAR) were reviewed. The MARs for (MONTH) (YEAR) and up to 4/21/18 revealed the resident received Med Pass 2.0, 3 ounces, 4 times per day. On 4/21/18 at 11:30 AM, according to the MAR, the resident started receiving Med Pass 2.0, 2 ounces, 4 times per day. On 5/2/18 at 2:13 PM, a Dietary Communication form dated 4/20/18 by Registered Dietician (RD) #120 was reviewed. The dietary request directed: 1. Prosource Plus (Dietary Supplement) 1 ounce twice a day. 2. Please document the percentage of Med Pass 2.0 and magic cups that are already ordered in the MAR. The physician's orders [REDACTED]. The original order dated 12/10/15 directed Med Pass 2.0 before meals and at bedtime 3 ounces (4 times a day). A physician's orders [REDACTED]. On 5/3/18 at 11:52 AM the nutritional notes were reviewed. A nutritional note dated 5/3/18 indicated Please clarify the order for Med Pass 2.0 to be 3 ounces, 4 times per day. Document the percentage consumed in the MAR. Discontinue the order for Med pass 2.0, 2 ounces, 4 times per day as previously ordered. On 5/3/18 at 12:00 PM RD #120 was interviewed. RD #120 reviewed the documentation in the medical record regarding the recommendation he made on 4/20/18. He stated in (MONTH) (YEAR) when dietary recommendations were made the nurse must have put the wrong amount of the Med Pass 2.0 into the computer. RD #120 stated the order was for Med Pass 2.0 3 ounces four times a day, but the documentation revealed the nurses were giving only 2 ounces four times a day. In an interview on 5/3/18 at 12:04 PM, Registered Nurse (RN) #41 verified the nurse entered the incorrect amount of supplement into the computer, causing the resident to miss 4 ounces of the supplement daily. RN #41 stated at the beginning of each month the nurses do a recapitulation to ensure that physician's orders [REDACTED]. RN #41 verified the nurse missed this error, as there was no new physician order [REDACTED].",2020-09-01
57,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2018-05-03,880,D,0,1,X20F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain an infection prevention program designed to help prevent the development and transmission of diseases and infections. Specifically, the facility failed to keep Resident #301's [MEDICAL CONDITION] tubing off of the floor. This failed practice had the potential to affect a limited number of residents. Resident identifier: #301. Facility census: 142. Findings included: a) Resident #301 Resident #301 admitted to the facility on [DATE]. According to the 5/18 physician orders, [DIAGNOSES REDACTED]. The resident had orders for a [MEDICAL CONDITION]. Review of the 4/24/18 Minimum Data Set (MDS) assessment, on 5/2/18 at 9:05 AM revealed Resident #301 was in a vegetative state with no discernible consciousness. He required total care for all activities of daily living (ADL). He was identified as receiving [MEDICAL CONDITION] care, suctioning, and oxygen. Multiple observations were made of the resident throughout the day from 4/30/18 to 5/3/18. During each of these observations, the resident's [MEDICAL CONDITION] tubing was observed to be very long, with the tubing laying on the floor touching multiple objects next to the resident's bed. Specific observations included the following: On 4/30/18 at 10:57 AM, 5/1/18 at 4:51 PM, 5/2/18 at 12:01 PM, 5/2/18 at 4:58 PM and 5/3/18 at 8:49 AM, the resident's [MEDICAL CONDITION] tubing was observed laying on the floor touching multiple objects next to the resident's bed. On 5/2/18 from 7:53 AM to 8:11 AM, [MEDICAL CONDITION] care was observed to be given by Licensed Practical Nurse (LPN) #4. She suctioned the resident, cleaned around the [MEDICAL CONDITION], and changed the soiled gauze around the [MEDICAL CONDITION]. The [MEDICAL CONDITION] tubing was observed to be laying on the ground the entire time the treatment occurred. In an interview on 5/3/18 at 8:55 AM, LPN #4 observed the resident's [MEDICAL CONDITION] tubing. She acknowledged the tubing was laying directly on the floor. She said the tubing should not be on the floor because of bacteria and for the draining of the humidity. There was a bag on the tubing that caught the excess liquid/humidity. She said it was supposed to be tied to the bed but the tie had broken. She said the resident had not had any infections and was doing well. She proceeded to get new tubing and change it. After she changed the tubing, the tubing was tied to the bed and off of the floor. In an interview on 5/3/18 at 9:16 AM, the Assistant Director of Nursing said [MEDICAL CONDITION] tubing should never touch the floor. Anything that touches the floor has the potential for infection. She said the tubing should be tied to the bed, so it was off the floor. In an interview on 5/3/18 at 10:44 AM, the Director of Nursing said [MEDICAL CONDITION] tubing should never be laying on the floor. She explained bacteria could potentially get in the [MEDICAL CONDITION] area.",2020-09-01
58,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,550,E,0,1,WJ7O11,"Based on observation and staff interview, the facility failed to treat each resident with respect and dignity, and failed to care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life. A nurse conducting medication administration did not knock or announce herself before entering Resident's rooms. This practice affected three (3) of four (4) residents observed during medication administration. Resident identifiers: #11, #71, and #101. Facility census: 140. Findings included: a) Observation An observation of Registered Nurse (RN) #5 during medication administration, on 08/05/19 at 08:05 AM, revealed the RN did not knock on the doors and announce herself before entering the rooms of Resident #11, #71, and #101. b) Interview An interview with RN #5, on 08/05/19 at 8:15 AM, revealed she usually knocks on the doors but forgot to because she was being observed and was nervous.",2020-09-01
59,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,558,D,0,1,WJ7O11,"Based on observation, record review, staff interview and policy review, the facility failed to provide reasonable accommodations to a resident. The facility failed to ensure resident's call light was within reach. This failed practice affected two (2) of 31 residents. Resident identifier: #130 and #111. Facility census: 140. Findings included: a) Resident #130 An observation, on 07/29/19 at 11:49 AM, revealed Resident #130's sheets and call light was laying on the floor by the foot of the bed. Resident #130 was in bed and unable to reach call light. An interview with Licensed Practical Nurse (LPN) #122, on 07/29/19 at 11:54 AM, confirmed call light was on floor and out of reach of Resident #130. LPN stated, I will go pick up her call light and change her sheets since hers are on the floor. A policy review Answering the Call Light with Revised date (MONTH) 2010. Policy stated, Step four (4) When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. b) Resident #111 An observation of the Resident, on 07/30/19 at 08:39 AM, revealed she was in bed. The call light was hanging off the side of the bed and was not within reach of the Resident. An interview with the Resident, on 07/30/19 at 8:40 AM, revealed she did not know where her call light was. An interview with Nurse Aide (NA) #100, on 07/30/19 at 8:45 AM, revealed all call lights should be within reach while residents are in bed. The NA placed the call light within reach.",2020-09-01
60,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,584,E,0,1,WJ7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to ensure comfortable and safe temperature levels for residents. The facility did not ensure the temperature range of 71 to 81 degrees Fahrenheit was maintained in the resident's Day/Dining Rooms. Three (3) Day/Dining Rooms tested higher than 81 degrees while being used by residents. The facility also failed to ensure a Broda Chair was not damaged and a wall in a resident's room was in good repair. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #62, #82, #21, #48, #110, & #115. Room identifiers: 100 Hall Day/Dining Room, 500 Hall Day/Dining Room, 600 Hall Day/Dining Room, 700 Hall Day/Dining Room, and the 800 Hall Day/Dining Room. Facility census: 140. Findings included: a) Temperature Observations An observation during the initial tour of the facility, on 07/29/19 at 11:15 AM, revealed the 100 Hall Day/Dining Room, 500 Hall Day/Dining Room, 600 Hall Day/Dining Room, 700 Hall Day/Dining Room, and 800 Hall Day/Dining Rooms all felt hot. There were no fans and the air conditioning units were only blowing warm air. These rooms are used as the main dining rooms for each hallway in the facility. An observation of the 600 Hall Day/Dining Room, on 07/29/19 at 12:55 PM, revealed the room felt hot. Resident #62 was attempting to eat her lunch and was visibly sweating. A room thermometer affixed to the wall read 83 Degrees Fahrenheit. No staff were present. There were no fans and the air conditioning units were only blowing warm air. An observation of the 800 Hall Day/Dining Room, on 07/29/19 at 1:15 PM, revealed Nurse Aide (NA) #100 was assisting two (2) residents with their lunch. The room felt hot. There were no fans and the air conditioning units were only blowing warm air. An observation of the 700 Hall Day/Dining Room, on 07/29/19 at 2:15 PM, revealed a room thermometer affixed to the wall read 82 Degrees Fahrenheit. Two residents were in the room at the time of the observation. There were no fans and the air conditioning units were only blowing warm air. b) Temperature Interviews/Record Review An interview with Resident #82, on 07/29/19 at 11:41 PM, revealed the day room where we eat here on wing one is hot and the air conditioner has been out for a while. The Resident revealed on 07/28/19 the room got as hot as 84 degree Fahrenheit and that it was too hot to eat in there. An additional interview with Resident #82, on 07/29/19 at 3:00 PM, revealed, I eat in the dining room because there is nowhere else to eat. I really don't like to eat in my room. An interview with Resident #21, on 07/29/19 at 12:10 PM, revealed the dining room is so hot but there is nowhere else to eat. An additional interview with Resident #21, on 07/29/19 03:00 PM, revealed I eat in the dining room because there is nowhere else to eat. I have tried to eat at all the other dining rooms in the other wings but they are just as hot if not hotter. A family interview with Resident #48's husband, on 07/29/19 at 12:44 PM, revealed, the Day/Dining Room on Wing 100 had no air conditioning. He stated the air conditioning had not been working for a while. Resident #48's husband stated, they have the unit on the wall blowing as a fan from outside but it has only made the rooms hotter especially on the hottest days. Resident #48's husband stated, I bought a room thermometer and brought it to the facility to watch how hot it gets in the room. The room temperature has been as hot as 86 degrees Fahrenheit. Resident #48's husband stated I have addressed the air conditioning issue with the facility multiple times but the problem has yet to be fixed. An interview with Resident #62, on 07/29/19 at 1:00 PM, revealed the dining room is always hot. The Resident asked can't you see me sweating? The Resident stated she had complained to multiple staff members about the temperature but nobody had addressed her complaints. The Resident stated the only other place she can eat is in her room and she does not want to do that. An interview with NA #100, on 07/29/19 at 1:20 PM, revealed the Day/Dining Rooms have been hot for months. The NA stated it makes it hard to do my job and I know the residents hate it. The NA stated the rooms have been hot all summer. The NA stated the rooms have never been closed when she works. An interview with Registered Nurse (RN) #5, on 07/29/19 at 1:30 PM, revealed the facility has been too hot the past few months. The RN stated the administration ignores the hot temperatures while they sit in their air conditioning downstairs. The RN stated multiple residents eat in the Day/Dining Rooms on each unit daily with no air conditioning or fans. The RN stated she had never seen the Day/Dining Rooms closed. The RN stated the residents have no other places to eat their meals besides in their rooms which is no kind of life. An interview with the Maintenance Director in the 800 Hall Day/Dining Room, on 07/29/19 at 1:45 PM, revealed the facility addressed the hot Day/Dining Rooms in (MONTH) 2019. The Maintenance Director stated the air conditioning units either do not work or cannot cool the Day/Dining Rooms adequately during the summer. The Maintenance Director stated the resolution set by the Administrator and himself was to close the Day/Dining Rooms when the temperature went above 81 degrees Fahrenheit. The Maintenance Director stated the facility had ordered new portable air conditioner units but they had to be utilized in other areas of the facility. The Maintenance Director verified the room felt hot and stated no residents should be in here until we get the permanent air conditioners installed. The Maintenance Director stated I thought they were closing these rooms on days like today. The Maintenance Director stated some of the rooms have wall thermometers and some do not. The Maintenance Director stated the facility bought a thermometer gun recently to test temperatures daily but is unsure who is checking them. Further interview with the Maintenance Director, on 07/29/19 at 2:15 PM, revealed he found the thermometer gun and would check the temperatures in the Day/Dining Rooms. The following Day/Dining Room temperatures were recorded at 2:15 PM on 07/29/19 with the facility's thermometer gun: 600 Hall Day/Dining room [ROOM NUMBER].0 800 Hall Day/Dining room [ROOM NUMBER].5 The Maintenance Director verified on 07/29/19 at 2:20 PM the wall thermometer in the 600 Hall Day/Dining room read 83 Degrees Fahrenheit. An interview with the Administrator, on 07/29/19 at 3:00 PM, revealed he stated I am not confirming anything or divulging any information about the temperatures and what we have in place. An interview with the Corporate Consultant (CC) #154, on 07/29/19 at 3:15 PM, revealed she would check into the temperature situation and report back. Further interview with the Administrator, on 07/29/19 at 3:30 PM, revealed the facility had addressed the hot temperatures and put a plan in place on 06/01/19. The Administrator provided the written plan, dated 06/01/19, that stated hot temperatures identified in several areas throughout the facility which included Morning/evening temperature checks and documented to monitor ambient conditions. A review of the temperature logs revealed they were only recorded on 07/08/19 and 07/09/19. The log stated to call the Administrator if temperatures are above 82 Degrees. The temperatures recorded on those days were: 100 Hall-12:30 PM 83.5 Degrees Fahrenheit 300 Hall-12:30 PM 82 Degrees Fahrenheit 600 Hall-12:30 PM 82 Degrees Fahrenheit 700 Hall-12:30 PM 82.5 Degrees Fahrenheit The Administrator stated he had no other temperature logs from 06/01/19 to 07/29/19. The Administrator stated he could not provide any evidence the high temperatures recorded on the logs were addressed. The Administrator stated he could not provide any further documentation the facility had protected the residents from the high temperatures in the facility since 06/01/19. An interview with the CC #154, on 08/05/19 at 12:30 PM, revealed the facility had no written policy for room temperatures. The CC stated we follow life safety code and the regulation of keeping temperatures between 71 and 81 degrees Fahrenheit.",2020-09-01
63,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,610,D,0,1,WJ7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview the facility failed to thoroughly investigate an allegation of abuse/neglect related to a threat to discharge Resident #239, if she refused to go to an appointment and an allegation the nursing staff gave [MEDICATION NAME] to the van driver to dispense to Resident #239, while out of the facility. This is true for one (1) of two (2) complaint concerns reviewed. Resident identifier: #239. Facility census: 140. Findings included: a) Resident #239 Resident #239 filed a grievance with Social Services, (SS) #111, on 02/14/19 concerning a threat made by facility staff that she would be discharged if she did not go to an appointment scheduled for this same day. In addition, Resident #239 complained she did not believe the nursing staff should give [MEDICATION NAME] to the van driver to dispense to her, while out of the facility. On 02/14/19 the complaint/grievance form was signed by SS #111, and the risk manager registered nurse (RN), #136. The DON signed the resolution section of the complaint/grievance on 02/15/19 documenting the grievance was resolved and the complainant is satisfied. There no evidence the facility thoroughly investigated these allegations. On 02/25/19 RN #136, sent an e-mail to the DON an information statement regarding completing an investigation, by gathering witness statements and determining if Resident #239's rights were violated. On 07/31/19 at 4:00 PM the director of nursing expressed a thorough investigation did not occur related to the allegation of threatening to discharge Resident #239, and to medication being sent with the van driver. On 08/05/19 at 3:58 PM the DON agreed sending medication with the van driver was inappropriate.",2020-09-01
64,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,623,D,0,1,WJ7O11,"**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 of resident transfers to an acute care setting. This was found for two (2) of two (2) residents reviewed for hospitalization s. Resident identifiers: #133 and #130. Facility census: 140. Findings included: a) Resident #133 Review of the medical record on 07/31/19, revealed Resident (R) #133 was admitted to the facility on [DATE] and discharged to the hospital after a fall on 05/29/19. The medical record is silent in regard to the Ombudsman being notified of the unplanned transfer and admission to the hospital. During an interview on 07/31/19 at 1:20 PM, social workers (SW) #134 and #111, acknowledged the Ombudsman was not notified. SW #134 stated, We just started notifying the Ombudsman on 07/01/19, after the new Administrator identified the issue. b) Resident #130 During a medical record review on 07/31/19 at 1:19 PM, found no evidence of a bed hold or ombudsman notification for hospitalization s on 04/28/19, 05/31/19 and 06/30/19. Employee #111 and Employee #134 reported on 07/31/19 at 1:20 PM, the facility just started notifying the ombudsman on 7/1/19. On 07/31/19 at 1:30 PM, Employee #40 and Employee #147 explained she (Resident #130) is on Medicaid so it is automatically a twelve (12) day bed hold. Upon further inquiry Employee #40 stated, We just heard that we need to notify the ombudsman for hospitalization s. Employee #40 and Employee #147 verified the medical record did not contain any notification for hospitalization s on 04/28/19, 05/31/19 and 06/30/19.",2020-09-01
65,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,625,D,0,1,WJ7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide the resident and/or family with a copy of the Bed-Hold notification on admission and/or at the time of transfer. This was found for one (1) of two (2) residents reviewed for hospitalization . Resident identifier: #133. Facility census: 140. Findings included: a) Review of the medical record on 07/31/19, revealed Resident (R) #133 was admitted to the facility on [DATE] and discharged to the hospital after a fall on 05/29/19. The medical record is silent regarding the resident and/or Medical Power of Attorney receiving information related to the facility's bed-hold policy on admission or at the time of the unplanned transfer to the hospital. Social Worker (SW) #111 reported the business office staff review the bed-hold policy with the resident and/or family on admission. SW #111 reviewed the electronic medical record and confirmed it lacked any information related to this policy. At 11:42 AM on 07/31/19, the Business office Manager (BOM) acknowledged she reviews the bed-hold policy with the resident and/or family on admission and a signed copy is placed in the medical record. The BOM reported the nurse is to complete a second bed-hold notification when the resident is transferred to the hospital. On 07/31/19 at 12:30 PM, SW #134, verified R#133's medical record lacks any information indicating the bed-hold policy was reviewed and/or given to the resident and/or family during admission or at the time of the hospital transfer.",2020-09-01
66,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,640,D,0,1,WJ7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to transmit a resident assessment within 14 days after completion. This was true for one (1) of 31 residents reviewed. Resident identifier: #1. Facility census: 140. Findings included: a) Review of the medical record on 07/31/19, revealed Resident (R) #1 was admitted to the facility on [DATE] and discharged to home 02/26/19. The status section of the electronic minimum data set (MDS) assessment for the five (5) day admission assessment dated [DATE], the 14-day assessment dated [DATE] and the discharge return not anticipated assessment dated [DATE], all state assessment was never added to batch. The status section of R #1's MDS assessments was reviewed by corporate consultant (CC) #152 and Registered Nurse Assessment Coordinator (RNAC) #33, during an interview on 07/31/19 at 3:45 PM. CC#152 acknowledged the status was marked incorrectly and the discharge assessment was never submitted. CC #152 corrected the discharge assessment and submitted it during this interview.",2020-09-01
67,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,641,D,0,1,WJ7O11,"Based on record review, staff interview and Minimum Data Set (MDS) Resident Assessment Instrument (RAI) version 3.0 manual, the facility failed to ensure the accuracy of a MDS for a resident receiving Hospice services. This practice was found for one (1) of one (1) residents reviewed for Hospice services. Resident identifier: #130. Facility census: 140. Findings included: a) Resident #130 On 07/31/19 at 11:45 AM, review of the medical record revealed Resident #130 was admitted to Hospice services on 07/19/19. Review of the significant change MDS with assessment reference date (ARD) of 07/21/19 discovered the following: Section J, titled Health Conditions, J1400 Prognosis, coded as: NO. MDS RAI version 3.0 manual coding instructions for J1400 Prognosis (typed as written): . --Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services. After review of the significant change MDS with ARD of 07/21/19 on 07/31/19 at 11:55, Employee #152 stated, Yes, the manual states it should be coded yes because the resident is on Hospice. But the coordinator was waiting on physician documentation. Yes, if you follow the manual which they are supposed to, it is coded wrong.",2020-09-01
68,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,656,D,0,1,WJ7O11,"Based on record review, hospice contract review and staff interview, the facility failed to implement and/or develop a comprehensive person-centered care plan. A resident's call light was not within reach as directed by their care plan and a resident receiving hospice services did not have a care plan that included a detailed description of the services being provided. These practices affected two (2) of thirty-one (31) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #111 and #130. Facility census: 140. Findings included: a) Resident #111 An observation of the Resident, on 07/30/19 at 08:39 AM, revealed she was in bed. The call light was hanging off the side of the bed and was not within reach of the Resident. An interview with the Resident, on 07/30/19 at 8:40 AM, revealed she did not know where her call light was. An interview with Nurse Aide (NA) #100, on 07/30/19 at 8:45 AM, revealed all call lights should be within reach while residents are in bed. The NA placed the call light within reach. A review of the Resident's Care Plan, on 07/30/19 at 10:15 AM, revealed the focus History of falls with the intervention keep call light within reach. The Care Plan was initiated on 3/31/2017. b) Resident #130 On 07/31/19 at 11:45 AM, review of the medical record revealed Resident #130 was admitted to Hospice services on 07/19/19. Review of the care plan revealed an intervention created on 07/19/19 stating (typed as written): . Hospice staff to visit to provide care, assistance and/or evaluation . The care plan lacked a goal related to Hospice care and/or services. After review of the care plan on 07/31/19 at 12:35 PM, the Director of Nursing (DON) agreed the care plan was not individualized with measurable goals and interventions. She further agreed the care plan did not specify what Hospice staff would visit and when the visits would occur.",2020-09-01
69,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,657,D,0,1,WJ7O11,"Based on resident interview, record review and staff interview the facility failed to ensure a resident was invited to a care plan meeting. The facility failed to ensure a resident had the right to participate in choosing treatment options and was given the opportunity to participate in the development, review and revision of the care plan. The failed practice affected one (1) of 31 residents. Resident identifier: Resident #7. Facility census: 140. Findings included: a) Resident #7 A resident interview, on 07/29/19 at 1:00 PM, Resident #7 revealed questions about medication orders and administration. Resident #7 stated, I have tried to ask the nurses and doctors about my meds but they are always too busy, I would like to know what medications I am taking and why I need to take them. A record review, on 07/31/19 at 10:00 AM, revealed a social service note dated for 07/24/19 that stated, SW talked with brother (name of brother), MPOA, and updated him on IDT review. He is not interested in having a quarterly review meeting. He visits regularly and is aware of (resident's name) condition and daily routine. (Resident's name) continues attending activities of choice and interacts well with other residents. He is aware to contact SW with questions/concerns. A second social service note found dated for 05/24/18, stated, SW talked with brother (brother;s name) by phone and updated him on IDT review of treatment plan and asked if he would like to schedule a meeting. (Brother's name) visits regularly and is aware of (resident's name) condition and daily routine. He was not interested in having a meeting. (Resident's name) attends activities of choice and interacts well with staff, residents and visitors. He is well adjusted to long term care and aware to contact SW with questions/concerns. Further record review, on 07/31/19, revealed Resident #7 has a current Brief Interview for Mental Status (BIMS) of 15. An interview with Social Worker (SW) #134, on 07/31/19 at 11:08 AM, revealed no documentation that Resident # 7 was ever invited to a care plan meeting. SW #7 stated, I always talk to Resident #7's Medical Power of Attorney (MPOA) with Resident #7 present about the Care Plan Meetings after meeting is held. SW #134 confirmed the facility completes Care Plan Meetings and then updates the MPOA and Resident #7 after meeting occurred.",2020-09-01
72,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,689,D,0,1,WJ7O11,"Based on observation and staff interview, the facility failed to provide an environment free of accident hazards over which it had control. The facility failed to secure hot liquids from resident's access. The 700 Hall Nourishment Room contained a coffee maker that was left unattended and brewing with hot coffee in the pitcher. The room, which is located on the resident hallway, had no door and was accessible to anyone. There was a resident observed seated in a wheelchair at the entrance of the Nourishment Room. No staff was in sight of the Nourishment Room at the time of the observation. The coffee inside the pitcher was tested to be 184.6 degrees Fahrenheit by the facility's Maintenance Director. An observation of the first floor lobby, on 07/29/19 at 4:30 PM, revealed three (3) male residents sitting in the lobby. Resident #121 was observed independently pouring a cup of coffee from a coffee maker that was on a counter in the lobby. The coffee maker, which was unsupervised at the time of the observation, had coffee readily available. The coffee was then poured into a cup and tested at 161 degrees Fahrenheit. The facility also failed to secure chemicals and sharp objects and to keep resident area floor's dry. All the deficient practices had the potential to affect more than a limited number of residents residing in the facility. Room identifiers: 700 Hall Nourishment Room, First Floor Lobby, 600 Hall Soiled Utility Room, and 100 Hall Shower Room. Facility census: 140. Findings included: a) 700 Hall Nourishment Room An observation of the 700 Hall Nourishment Room, on 07/29/19 at 11:30 AM, revealed a coffee maker noted to be brewing with six (6) ounces of coffee in the pot. The coffee was situated on the countertop approximately three (3) inches from the edge of the counter. There was no separation or door to the Nourishment Room from the resident hallway. Residents were observed walking by as well as one resident seated in a wheelchair at the entrance of the Nourishment Room. An interview with Licensed Practical Nurse (LPN) #1, on 07/29/19 at 11:30 AM, revealed the coffee was for staff and not the residents. The LPN verified that any mobile Residents in the facility had access to the coffee maker. A temperature test conducted by the facility's Maintenance Director, on 07/29/19 at 11:50 AM, revealed the coffee was 184.6 Degrees Fahrenheit. An interview with the Maintenance Director, on 07/29/19 at 11:50 AM, revealed the Maintenance Director stated that's pretty hot, I did not know this coffee maker was here. Further observations, on 07/29/19 at 12:00 PM, revealed six (6) other Nourishment Rooms within the facility had coffee makers on their counters with brewing capacity and supplies. An interview with the Administrator, on 07/29/19 at 12:26 PM, revealed he had been notified of the coffee on the 700 Hall and its temperature of 184.6 degrees Fahrenheit. The Administrator stated he had taken care of it. b) First Floor Lobby An observation of the First Floor Lobby, on 07/29/19 at 4:30 PM, revealed a self-service coffee maker. Three residents were noted to be seated in wheelchairs, in close proximity to the coffee maker. Resident #121 was serving himself coffee from the coffee maker unsupervised. A temperature test of the coffee maker, on 07/29/19 at 04:30 PM, revealed the coffee was 161 Degrees Fahrenheit. The temperature was verified by the Assistant Director of Nursing (ADON). The ADON stated I will take care of that right now. An interview with the Administrator, on 07/29/19 at 05:15 PM, revealed he was aware of the self-service coffee maker in the First Floor Lobby. c) 600 Hall Soiled Utility Room An observation of the 600 Hall, on 07/30/19 at 10:00 AM, revealed the room labeled Soiled Utility Room was unlocked. No staff were in sight of the room at the time of the observation. The room contained the following items in an unlocked cabinet: One (1) bottle of Peroxide Multi-Surface Cleaner and Disinfectant with the warning Keep out of reach of children. Ten (10) capped shaving razors Two (2) unsecured razor blades Fifteen (15) tacks Four (4) large glass vases An interview with Registered Nurse (RN) #105, on 07/30/19 at 10:10 AM, revealed the room should have never been unlocked. The RN stated she would ensure the room was locked. d) Wing one (1) Shower Room A resident interview, on 07/31/19 at 9:00 AM, revealed a concern in the shower room. Resident #21 stated, when I go into the shower the water overflows onto the floor. Resident #21 stated, with all the water on the floor someone is going to fall and get hurt. An observation of Wing one (1) Shower Room, on 07/31/19 at 12:05 PM, revealed a shower that water flowed out the sides of the shower stall onto the bathroom floor. An immediate staff interview with Certified Nursing Assistant (CNA) #6, on 07/31/19 at 12:05 PM, revealed, The shower water flows out on the floor a lot. CNA #6 stated, if you hold the handheld shower head it doesn't flow over into the floor as bad.",2020-09-01
73,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,692,D,0,1,WJ7O11,"Based on family interview, record review, staff interview, the facility failed to ensure a resident maintained an acceptable parameter of nutritional status. A resident who was admitted under weight, was not weighed after a decline in status. This is true for one (1) of nine (9) residents reviewed for nutrition. Resident identifier: #126. Facility census: 140. Findings included: a) Resident #126 On 07/29/19 at 12:25 PM Resident #126's wife expressed she did not think the facility was weighting her husband, she requested his weight be obtained, and she is concerned about how very thin he is. Review of medical records found the admit weight on 06/21/19 to be one-hundred and thirteen (113) pounds. Additional weights on 07/07/19, 07/05/19, remained at (113) pounds. On 07/12/19 the residents weight was one-hundred and twelve (112) pounds. On 07/31/19 the surveyor requested the facility weight the resident. The residents weight was one-hundred and seven (107) pounds which represents a five (5) percent weight loss between 07/12/19 and 07/31/19. Observation of the resident during the survey found the resident to appear very weak, and with very low energy. The facility followed the weight admission orders [REDACTED].",2020-09-01
76,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,756,F,0,1,WJ7O11,"Based on policy review and staff interview, the facility failed to develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the monthly medication regimen review (MRR) process. This practice has the potential to affect all residents. Facility census: 140. Findings included: a) The facility policy titled Consultant Pharmacist Reports with an effective date of (MONTH) 23, 2019, states the Consultant Pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. --Comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication review. In the event of a problem requiring the immediate attention of the prescriber, the responsible prescriber or physician's designee is contacted by the consultant pharmacist or the facility, and the prescriber response is documented on the consultant pharmacist review record or elsewhere in the resident's medical record. --Recommendations are acted upon and documented by the facility staff and/or the prescriber in non-urgent cases within 30 days. If the prescriber does not respond to the recommendations directed to him/her, the Director of Nursing (DON) and/or the consultant pharmacist, may contact the Medical Director. The policy lacked specific time frames for facility notification including Physician notification and response time for urgent and non-urgent recommendations. After review of the facility MRR policy on 07/31/19 at 3:25 PM, the Director of Nursing (DON) verified the policy did not contain detailed specific time frames for facility notification including Physician notification and response time for urgent and non-urgent recommendations. She stated, the pharmacist is here monthly, does notify us in writing and there has not been a problem.",2020-09-01
77,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,761,E,0,1,WJ7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff 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. Multiple opened medications stored in the 100, 200, and 300 Hall Medication Carts were unlabeled and undated. This practice had the potential to affect more than a limited number of residents. Facility census: 140. Findings include: a) 100 Hall Medication Cart An observation of the 100 Hall Medication Cart, on 08/05/19 at 8:26 AM, revealed the following items: --One (1) bottle of opened and undated Fiber Caps. --Two (2) bottles of opened and undated Senna tablets. --One (1) bottle of opened and undated [MEDICATION NAME] tablets. --One (1) unidentified white pill was at the bottom of the medication cart. --One (1) package of opened and undated [MEDICATION NAME] Sodium tablet. An interview with Registered Nurse (RN) #5, on 08/05/19 at 8:30 AM, revealed all medications should be dated when opened. b) 200 Hall Medication Cart An observation of the 200 Hall Medication Cart, on 08/05/19 at 8:38 AM, revealed the following items: --One (1) package of Gas-X with an expiration of 03/2014. --One (1) package of [MEDICATION NAME] with an expiration of (YEAR). --One (1) opened package of [MEDICATION NAME] Suppositories with no open date. An interview with Licensed Practical Nurse (LPN) #113, on 08/05/19 at 8:40 AM, revealed she was not sure why the medications had not been dated or thrown away. c) 300 Hall Medication Cart An observation of the 300 Hall Medication Cart, on 08/05/19 at 8:52 AM, revealed the following items: --One (1) weekly pill [MEDICATION NAME] with three unidentified (3) pills in each of the seven (7) daily spots. There was no name on the [MEDICATION NAME]. --One (1) bottle of opened and undated Sodium [MEDICATION NAME]. --One (1) pack of opened and undated Sore Throat [MEDICATION NAME]. --Two (2) bottles of opened and undated Cough Suppressant. An interview with LPN #7, on 08/05/19 at 8:53 AM, revealed she did not know who the pill [MEDICATION NAME] belonged to. She also did not know what pills were inside the [MEDICATION NAME]. The LPN stated when medication is opened then the package or bottle should be dated as to when it was opened.",2020-09-01
78,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,802,E,0,1,WJ7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review and temperature logs review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of nutritional services. The facility failed to provide staff that exhibited competent skills sets in hygiene and food preparation. The failed practice had the potential to affected more than an unlimited number of residents. Facility census: 140. Findings included: a) Kitchen An observation, on 07/30/19 at 11:13 AM, revealed Dietary Cook (DC) #93 washed and dried hands with a paper towel. DC #93 preceded to a trash can and used hand to lift the lid and throw away the paper towel. An immediate interview with Dietary Supervisor (DS) #142 revealed no concern with hand washing practice. DS #142 stated DC was supposed to use the trash can around the corner with the foot pedal. DS #142 immediately took the trash can with manual lid out of the kitchen area. An observation, on 07/30/19 at 11:40 AM, revealed DS #142's hand washing practice. DS #142 washed hands, turned the water facet off with her washed hands and then manually used the lever on the paper towel dispenser with washed hands. DC #93 was observed next and also washed hands, turned the water facet off with her washed hands and then manually used the lever on the paper towel dispenser with washed hands. An immediate interview with DS #142, stated, I have always done it this way. DS #142 stated, If I wash my hands and am not allowed to touch the handles of the sink how am I supposed to turn the sink off? An observation, on 07/30/19 at 11:41 AM, revealed DC #53 transferring hot metal containers with a dirty towel. DC #53 placed towels on a soiled countertop and used towels to transfer metal containers of food from the oven to countertop. DC #53 was observed holding the metal containers by the top inside of the metal container with the dirty towels. An immediate interview with DS #142 confirmed the use of a dirty towel to transfer hot metal containers was not a sanitary practice. An observation, on 07/30/19 at 11:55 AM, revealed the mechanical meat was taken out of the oven and placed on the counter to be temped. The mechanical meat was temped and ready to be served. The mechanical meat was visibly burned. Without surveyor intervention, the burned meat would have been served to residents. An immediate interview with DS #142 confirmed the mechanical meat was burned and directed the dietary staff to discard. An observation, on 07/30/19 at 12:05 PM, revealed DC #14, touched nonfood items cross contaminating hands and food. DC #14 was observed touching table top and bread bag while prepared sandwiches for residents. An immediate interview with DC #14 revealed lack of knowledge of cross contamination. DC #14 stated, I am new I did not know that was considered cross contamination and wrong. An observation, on 07/30/19 at 12:14 PM, revealed DC #53 prepared the mechanically altered and pureed meat. DC #53 was observed placing the plastic top if the puree machine on the dirty table and back on the machine. An immediate interview with DC #53 revealed, I knew I cross contaminated just as soon as I put that piece back on there. An observation, on 07/30/19 at 12:18 PM, revealed DC #53 temping food. DC # 53 stated that meats should be cooked at a temp of 140 degrees Fahrenheit (F). DS # 142 stated meat should be cooked to 150 degrees F. An interview with Dietitian, on 07/30/19 at 2:00 PM, confirmed meat should be cooked to a temperature of 165-degree F. An observation, on 07/30/19 at 12:35 PM, revealed DC #14 cross contaminating the residents' plates. DC #14 placed the red suction used to obtain resident plates on dirty table and continued to use dirty suction on plates. This affected 10 plates before observed. An immediate interview with DS #142 confirmed cross contamination and directed DC #14 to place suction a clean towel and not directly on dirty table. An observation, on 07/30/19 at 12:40 PM, revealed DC #53 cross contaminating. DC #53 was observed touching nonfood items with clean gloves that was used for serving the food. An immediate interview with DC #53 and DS #142 confirmed cross contamination. DS #142 directed DC #53 to wash hands and put new pair of clean gloves on prior to serving any more food. An observation, on 07/30/19 at 12:50 PM revealed DC #35 caught second mistake on a tray. DC #35 caught to regular trays prepared when tray should have been both mechanically altered trays. An observation, on 07/30/19 at 1:00 PM, revealed DC #93 touch tops of counters and served food with the same gloved hands. An immediate interview with DC #93 stated, I didn't even realize I was doing that. An observation, on 07/30/19 at 1:13 PM, revealed DC #35 caught the fifth wrong tray made as a regular diet tray when tray should have been mechanically altered or pureed. An immediate interview with DS #142 revealed DC #35 is in that serving position because mistakes are made regularly and DC #35 has a history to find the mistakes before they go out of the kitchen area. An interview with DC #35, on 07/30/19 at 1:14 PM, stated, I am off on Thursdays, I hope there are no mistakes when I am off. An observation, on 07/30/19 at 1:20 PM, revealed DC # 85 wore hairnet in an inappropriate way. DC # 85 had hairnet that covered half of head with bangs in front of head not covered. An immediate interview with DS #142 confirmed hairnet did not cover DC # 85 hair entirely. DS #142 directed DC #85 to cover entire hair with hairnet. An observation on 07/30/19 at 1:25 PM revealed DC #35 caught sixth tray with the wrong dietary needs for resident. Tray was made as a regular diet tray but should have been made as a mechanically altered tray. An interview with DS #142 stated, that is his job to ensure the residents get the correct diet as he is the best at catching all the mistakes. An observation, on 07/30/19 at 1:28 PM, revealed DC # 93 cutting meat on a visibly soiled counter. DC # 93 was observed cutting meat on a visibly soiled countertop and then placed cut meat on a resident's tray. An immediate Interview with DS #142 and DC #93 confirmed preparing food in an unsanitary manner. DC #93 stated, where do you want me to cut the meat for the plate then? DS #142 immediately directed DC #93 why cutting the meat on the table was unsanitary. A staff interview with DS #142, on 07/30/19 at 1:30 PM, revealed DS #142 displeasure with kitchen staff and future training. DS #142 stated, They are a lost cause. DS #142 stated had [AGE] years of experience worked in the facility kitchen. DS # 142 stated, I have only been DS since Oct (YEAR) and have not been able to take the Safe Serve certification yet. An observation, on 07/30/19 at 1:48 PM, revealed a brown shelled bug with antennas crawling on the kitchen wall above the steam tables. An immediate interview with Dietitian occurred and bug was pointed out to Dietitian. The Dietitian stated, Oh that stinks. The bug was not obtained off the wall and then disappeared to wander the kitchen. A review of temperature logs, on 08/05/19 at 8:00 AM, revealed multiple incomplete temperature log forms for breakfast, lunch and dinner between the dates of 06/01/19 and 07/30/19. An interview with Dietitian, on 08/05/19 at 8:55 AM, confirmed, the policy is to take temps on foods to ensure food is served at the right temperature. A policy review of Handwashing/Hand Hygiene Policy with Revised date of (MONTH) (YEAR), on 08/05/19 at 9:15 AM, stated, Washing Hands Step three (3) Dry hands thoroughly with paper towel and then turn off faucets with a clean, dry paper towel.",2020-09-01
79,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,804,E,0,1,WJ7O11,"Based on observation, resident interview, test tray results and staff interview, the facility failed to serve food that is palpable, attractive, at safe temperatures, and with accuracy related to each residents tray card. This is true for 13 tray cards reviewed for the long term care survey process. This practice has the potential to effect more than a limited number. Resident identifiers: #181, #27, #94, #126, #49, #36, #238, #108, #231, #102, #119, #21, and #383. Facility census: 140. Findings included: a) The following tray cards with issues of accuracy include: 1. Resident #181 Resident: #181's noon meal on 07/30/19 had two (2) percent(%) milk. The tray card called for whole milk. 2. Resident #27 Resident #27's breakfast meal on 07/30/19 had french toast, dipped in eggs. The tray card reveals NO EGGS. 3. Resident #94 Resident #94's noon meal, on 07/30/19 did not include, a roll, and whole milk as listed on tray card. During interview at 1:45 PM, licensed nurse (LPN) #19, explained she did not think the resident would drink whole milk. 4. Resident #126 Resident #126's breakfast meal on 07/30/19 had 2% milk did not have syrup. The tray card reveals whole milk and syrup. 5. Resident #49 Resident #49's breakfast meal on 07/30/19; the tray card reveals resident to receive a renal diet. The resident did not receive juice as listed on the tray card. The resident prefers some kind of juice. She explained she could not receive orange juice because of being on a renal diet but was not offered an alternative juice. 6. Resident #36 The tray also included a banana which is high in potassium. Resident #36 explained her breakfast tray usually has a banana which is high in potassium. Potassium should be limited on a renal diet Resident #36's breakfast meal on 07/30/19, included french toast which appeared soggy. The resident did not eat and explained the french toast was soggy. 7. Resident #238 Resident #238's breakfast tray on 07/30/19 had 2% milk. The tray card lists whole milk. Resident #238 explained she request coffee but got hot water. The resident had put cream in hot water but could not drink. 8. Resident #108 Resident #108's breakfast tray on 07/30/19 did not include juice or syrup, both listed on the tray card. Also, received 2% milk with tray card listing whole milk. After surveyor request, the staff offered juice and called the kitchen for syrup. 9. Resident Council Meeting On 07/29/19 at 3:00 PM ten (10) of sixteen (16) residents attending Resident Council meeting agreed food served from the kitchen is often not palpable, and different from the tray card. 10. Interviews On 08/06/19 at 7:30 AM the dietary manager explained meals are dipped to the tray and then checked for accuracy before sending the tray to the floor. Also, that juice is passed out by staff on the floor. She also explained that the common fresh fruit sent to the residents, is bananas, apples and oranges. According to the dietary manager 2% milk has always been placed on trays but whole milk has been ordered. b) Dissatisfaction with food served 1. Resident # 36 An interview with Resident #36, on 07/29/19 at 12:03 PM, revealed a dislike to the food served. 2. Resident # 231 An interview with Resident #231, on 07/29/19 at 12:09 PM, revealed the food is poor. 3. Resident # 102 An interview with resident #102, on 07/29/19 at 12:09 PM, revealed the food is not good. 4. Resident # 119 An interview, on 07/29/19 at 04:01 PM, noted Resident #119 complained of receiving cold food and when soups are served, soups almost always required reheating because of cold temperatures. 5. Resident # 21 An interview with Resident # 21, on 07/29/19 at 12:12 PM, revealed the food is not the best. Resident #21 stated, they served my sandwich with the bread on top of the beets making it soggy. This has happened on many occasions. An additional interview with Resident # 21, on 07/31/19 at 9:00 AM, revealed, breakfast was served at a decent time however the minors scramble was not eaten due to the appearance of the food. Resident # 21 stated, the breakfast came at a decent time this morning but yesterday the food was late all day. 6) Resident # 383 and Test Tray An observation of food tray cart delivery on 07/31/19 at 1:10 PM to Wing five (5). The first tray was passed at 1:15 PM. A test tray of Resident # 383's tray was conducted at 1:26 PM. Resident # 383's tray was the last tray to be served in the cart. The tray was placed on the nurse's desk and both the surveyor and kitchen thermometers were used. The Dietitian thermometer and surveyor thermometer both revealed the same temperature for the coleslaw. The thermometers revealed the same reading and calibration. The results of the test tray were: --[NAME]slaw = 71 degrees Fahrenheit (F) --Baked Beans = 100 degrees F --Pulled Pork Sandwich = 118 degrees F --Milk-= 50 degrees F A taste test was conducted, on 07/31/19 at 1:28 PM, after the temping of the food items. The baked beans tasted good. The pulled pork had spice and tasted good. The coleslaw was warm and very bland. The milk was not tasted. An immediate interview with the Dietitian, on 07/31/19 at 1:28 PM, during the taste test revealed knowledge of the coleslaw being bland. The Dietitian stated, Oh you have to have some salt and pepper when eating coleslaw. Dietitian did not remark on the temperature of the food. A review of temperature logs, on 08/05/19 at 8:00 AM, revealed multiple incomplete temperature log forms for breakfast, lunch and dinner between the dates of 06/01/19 and 07/30/19. An interview with Dietitian, on 08/05/19 at 8:55 AM, confirmed, the policy is to take temps on foods to ensure food is served at the right temperature.",2020-09-01
80,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,809,E,0,1,WJ7O11,"Based on observation, resident interview, staff interview, record review and policy review, the facility failed to ensure no more than 14 hours elapsed between evening meals and breakfast. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #90 and #111. Hall identifier: 500 Hall. Facility census: 140. Findings included: a) Observations An observation of the 500 Hall, on 07/30/19 at 8:00 AM, revealed that breakfast trays had not been delivered to the floor or served yet. Further observation of the 500 Hall, on 07/30/19 at 8:30 AM, revealed that breakfast trays had not been brought to the floor or served yet. An observation of the 500 Hall, on 07/30/19 at 8:50 AM, revealed the trays were brought to the floor and the staff began to distribute them. b) Interviews An interview with Resident #90, on 07/30/19 at 7:30 AM, revealed she was hungry and sick of always waiting on breakfast. The Resident stated breakfast is not usually served on the 500 Hall until around 9:00 AM. The Resident stated her evening meal the day before was delivered at 5:45 PM. An interview with Resident #111, on 07/30/19 at 8:00 AM, revealed the meals are always late on the 500 Hall. An interview with Nurse Aide (NA) #104, on 07/30/19 at 8:40 AM, revealed the breakfast trays had not yet arrived. The NA stated they are always late on this hall. The NA stated this is the last hall to get trays in the whole building. The NA stated the trays usually come between 8:30 AM and 9:00 AM. The NA stated this is a daily thing. An interview with the Dietary Supervisor (DS), on 07/30/19 at 12:45 PM, revealed the 500 Hall is the last hall to receive trays. The DS stated breakfast should be served by 8:00 AM to all floors but that is only on a perfect day. c) Policy Review A review of the facility policy titled Meal Service with an effective date of 05-16-16. was conducted on 07/31/19. The policy stated Not more than 14 hours will elapse between the serving of the evening meal and the breakfast meal. The policy listed the evening meal time as 5:30 PM to 6:00 PM and the breakfast meal time as 7:30 AM to 8:00 AM.",2020-09-01
81,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,812,E,0,1,WJ7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review, test tray and review of temperature logs, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility failed to label and date food items in the walk-in refrigerator, freezer and dry storage area. The facility failed to prepare food in a safe and sanitary manner. The failed practice had the potential to affect more than unlimited number of residents. Facility census: 140. Findings included: a) Kitchen initial tour During the initial tour of the kitchen accompanied by the Dietary Supervisor (DS) #142, on 07/29/19 at 11:00 AM, revealed several food items not labeled or dated. The list of food items found were: --A metal container full of individual packets for salad dressing were found in the walk-in refrigerator dated 04/08/19. --Two (2) medium sized frozen cheese pizzas were found in the refrigerator with no date. --One (1) Full box of Baker Source garlic bread found in the freezer with box lid open and ice on garlic bread. Garlic bread appeared to be freezer burnt. --Two (2) brown bags of tri patties hash browns found in the freezer unlabeled and not dated. --Four (4) bags of Rice Crispies, two (2) pound bags, found in dry storage area not dated. --Five (5) bags of Corn Flakes, two (2) pound bags, found in dry storage area not dated. --Two (2) Pork Roast Gravy Mix, 11.3 ounces' packets, found in dry storage area not dated. An immediate interview with DS #142, on 07/29/19, acknowledged all items were not dated or labeled. DS #142 had dietary staff date and label items as items were found. b) Kitchen follow-up visit During the follow up visit in the kitchen, on 07/30/19, revealed several observations and interviews. The findings included multiple issues related to preparation of food in a safe and sanitary manner. An observation, on 07/30/19 at 11:13 AM, revealed Dietary Cook (DC) #93 washed and dried hands with a paper towel. DC #93 preceded to a trash can and used hand to lift the lid and throw away the paper towel. An immediate interview with Dietary Supervisor (DS) #142 revealed no concern with hand washing practice. DS #142 stated DC was supposed to use the trash can around the corner with the foot pedal. DS #142 immediately took the trash can with manual lid out of the kitchen area. An observation, on 07/30/19 at 11:40 AM, revealed DS #142's hand washing practice. DS #142 washed hands, turned the water facet off with her washed hands and then manually used the lever on the paper towel dispenser with washed hands. DC #93 was observed next and also washed hands, turned the water facet off with her washed hands and then manually used the lever on the paper towel dispenser with washed hands. An immediate interview with DS #142, stated, I have always done it this way. DS #142 stated, If I wash my hands and am not allowed to touch the handles of the sink how am I supposed to turn the sink off? An observation, on 07/30/19 at 11:41 AM, revealed DC #53 transferring hot metal containers with a dirty towel. DC #53 placed towels on a soiled countertop and used towels to transfer metal containers of food from the oven to countertop. DC #53 was observed holding the metal containers by the top inside of the metal container with the dirty towels. An immediate interview with DS #142 confirmed the use of a dirty towel to transfer hot metal containers was not a sanitary practice. An observation, on 07/30/19 at 11:55 AM, revealed the mechanical meat was taken out of the oven and placed on the counter to be temped. The mechanical meat was temped and ready to be served. The mechanical meat was visibly burned. Without surveyor intervention, the burned meat would have been served to residents. An immediate interview with DS #142 confirmed the mechanical meat was burned and directed the dietary staff to discard. An observation, on 07/30/19 at 12:05 PM, revealed DC #14, touched nonfood items cross contaminating hands and food. DC #14 was observed touching table top and bread bag while prepared sandwiches for residents. An immediate interview with DC #14 revealed lack of knowledge of cross contamination. DC #14 stated, I am new I did not know that was considered cross contamination and wrong. An observation, on 07/30/19 at 12:14 PM, revealed DC #53 prepared the mechanically altered and pureed meat. DC #53 was observed placing the plastic top if the puree machine on the dirty table and back on the machine. An immediate interview with DC #53 revealed, I knew I cross contaminated just as soon as I put that piece back on there. An observation, on 07/30/19 at 12:18 PM, revealed DC #53 temping food. DC # 53 stated that meats should be cooked at a temp of 140 degrees Fahrenheit (F). DS # 142 stated meat should be cooked to 150 degrees F. An interview with Dietitian, on 07/30/19 at 2:00 PM, confirmed meat should be cooked to a temperature of 165-degree F. An observation, on 07/30/19 at 12:35 PM, revealed DC #14 cross contaminating the residents' plates. DC #14 placed the red suction used to obtain resident plates on dirty table and continued to use dirty suction on plates. This affected 10 plates before observed. An immediate interview with DS #142 confirmed cross contamination and directed DC #14 to place suction a clean towel and not directly on dirty table. An observation, on 07/30/19 at 12:40 PM, revealed DC #53 cross contaminating. DC #53 was observed touching nonfood items with clean gloves that was used for serving the food. An immediate interview with DC #53 and DS #142 confirmed cross contamination. DS #142 directed DC #53 to wash hands and put new pair of clean gloves on prior to serving any more food. An observation, on 07/30/19 at 12:50 PM revealed DC #35 caught second mistake on a tray. DC #35 caught to regular trays prepared when tray should have been both mechanically altered trays. An observation, on 07/30/19 at 1:00 PM, revealed DC #93 touch tops of counters and served food with the same gloved hands. An immediate interview with DC #93 stated, I didn't even realize I was doing that. An observation, on 07/30/19 at 1:13 PM, revealed DC #35 caught the fifth wrong tray made as a regular diet tray when tray should have been mechanically altered or pureed. An immediate interview with DS #142 revealed DC #35 is in that serving position because mistakes are made regularly and DC #35 has a history to find the mistakes before they go out of the kitchen area. An interview with DC #35, on 07/30/19 at 1:14 PM, stated, I am off on Thursdays, I hope there are no mistakes when I am off. An observation, on 07/30/19 at 1:20 PM, revealed DC # 85 wore hairnet in an inappropriate way. DC # 85 had hairnet that covered half of head with bangs in front of head not covered. An immediate interview with DS #142 confirmed hairnet was not covering DC # 85 hair entirely. DS #142 directed DC #85 to cover entire hair with hairnet. An observation on 07/30/19 at 1:25 PM revealed DC #35 caught sixth tray with the wrong dietary needs for resident. Tray was made as a regular diet tray but should have been made as a mechanically altered tray. An interview with DS #142 stated, that is his job to ensure the residents get the correct diet as he is the best at catching all the mistakes. An observation, on 07/30/19 at 1:28 PM, revealed DC # 93 cutting meat on a visibly soiled counter. DC # 93 was observed cutting meat on a visibly soiled countertop and then placed cut meat on a resident's tray. An immediate Interview with DS #142 and DC #93 confirmed preparing food in an unsanitary manner. DC #93 stated, where do you want me to cut the meat for the plate then? DS #142 immediately directed DC #93 why cutting the meat on the table was unsanitary. A staff interview with DS #142, on 07/30/19 at 1:30 PM, revealed DS #142 displeasure with kitchen staff and future training. DS #142 stated, They are a lost cause. DS #142 stated had [AGE] years of experience worked in the facility kitchen. DS # 142 stated, I have only been DS since Oct (YEAR) and have not been able to take the Safe Serve certification yet. An observation, on 07/30/19 at 1:48 PM, revealed a brown shelled bug with antennas crawling on the kitchen wall above the steam tables. An immediate interview with Dietitian occurred and bug was pointed out to Dietitian. The Dietitian stated, Oh that stinks. The bug was not obtained off the wall and then disappeared to wander the kitchen. An observation on 07/30/19 at 4:11 PM, revealed approximately 12 gnats flying in the kitchen area. An interview with DC #126, on 07/30/19 at 4:13 PM, revealed the facility had a history of [REDACTED].#126 stated the bugs had been coming in through the floor drain. DC #126 stated the Dietitian placed green foam bug deterrents on the floor at night time but they are taken and put away during the daytime in the Dietitian office. A policy review of Handwashing/Hand Hygiene Policy with Revised date of (MONTH) (YEAR), on 08/05/19 at 9:15 AM, stated, Washing Hands Step three (3) Dry hands thoroughly with paper towel and then turn off faucets with a clean, dry paper towel. c) Food distribution wing five (5) An observation of food tray cart delivery to Wing five (5) on 07/31/19 at 1:10 PM. The first tray was passed at 1:15 PM. A test tray was conducted at 1:26 PM. The test tray was the last tray to be served in the cart. The tray was placed on the nurse's desk and both the surveyor and kitchen thermometers were used. The Dietitian thermometer and surveyor thermometer both revealed the same temperature for the coleslaw. The thermometers revealed the same reading and calibration. The results of the test tray were: --[NAME]slaw = 71 degrees Fahrenheit (F) --Baked Beans = 100 degrees F --Pulled Pork Sandwich = 118 degrees F --Milk-= 50 degrees F A taste test was conducted, on 07/31/19 at 1:28 PM, after the temping of the food items. The baked beans tasted good. The pulled pork had spice and tasted good. The coleslaw was warm and very bland. The milk was not tasted. An immediate interview with the Dietitian, on 07/31/19 at 1:28 PM, during the taste test revealed knowledge of the coleslaw being bland. The Dietitian stated, Oh you have to have some salt and pepper when eating coleslaw. Dietitian did not comment on the temperature of the food. A review of temperature logs, on 08/05/19 at 8:00 AM, revealed multiple incomplete temperature log forms for breakfast, lunch and dinner between the dates of 06/01/19 and 07/30/19. An interview with Dietitian, on 08/05/19 at 8:55 AM, confirmed, the policy is to take temps on foods to ensure food is served at the right temperature. d) Food distribution wing eight (8) An observation on 07/30/19 at 01:30 PM, revealed a partially eaten tray sitting on the counter in the nourishment area on Wing 8. The tray had been served and some food eaten by R#41. The tray lid was off and food exposed with a gnat flying around the food. The tray had Mashed potatoes, opened ice cream, ground red meat with 1/2 meat eaten, ground beige items and milk. An interview with CNA#43, on 07/30/19 at 01:30 PM, verified the partially eaten tray for Resident #41 was placed on the counter in the nourishment room with the lid off the food items. CNA #43 further stated I stuck that tray in here because I did not know where to put it. d) 500 Hall Nourishment Room An observation of the Nourishment Room, on 07/29/19 at 11:00 AM, revealed the room had no door and was readily accessible to any resident. The room contained the following items in unlocked cabinets: --Twenty-Five (25) packets of Smart Balance Buttery Spread with the label Keep Refrigerated. --Twenty (20) packets of undated McDonalds Ketchup. --Three (3) packets of undated grape jelly. One (1) packet was open. --Fifteen (15) packets of undated saltine crackers. Three (3) packets were open. --Eight (8) packets of undated peanut butter. --One (1) container of undated and opened[NAME]House Coffee. --Fifteen (15) packs of undated honey mustard dressing. --Twenty (20) packs of undated hot chocolate --Twenty (22) packs of undated mustard --Five (5) packs of undated mayonnaise. --Eight (8) containers of undated coffee creamers. An interview with Nurse Aide (NA) #104, on 07/29/19 at 11:05 AM, revealed she had no idea what the dates were for the food items. The NA stated she would discard the undated and opened food items.",2020-09-01
82,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,849,D,0,1,WJ7O11,"Based on medical record review, Hospice service contract and staff interview, the facility failed to ensure in accordance with the agreement/contract prescribed Hospice services were provided to a resident. This practice was found for one (1) of one (1) Hospice resident reviewed during the survey. Resident identifier: #130. Facility census: 140. Findings included: a) Resident #130 On 07/31/19 at 11:45 AM, review of the medical record revealed Resident #130 was admitted to Hospice services on 07/19/19 for a terminal health condition. Continued review of the medical record found no evidence of documentation of further Hospice care visits following her admission to Hospice services. Review of the Hospice care plan created on admission was silent for the identification of services to be provided. Review of the facility agreement/contract with the contracted Hospice services provided by the Director of Nursing (DON) revealed the following (typed as written): --Hospice shall develop the Plan of care to be provided to the Home specifying information pertinent to the resident's treatment. The Plan will be updated bi-weekly by the hospice team . --Documentation of all visits by Hospice staff shall be placed on the Home chart at the time of the visit . After reviewing the medical record on 07/31/19 at 12:35 PM, the DON was unable to locate documentation of Hospice visits following Resident #130's initial admission to Hospice services. The DON stated, I am sure that they have been here to visit, but there is nothing to prove it. I agree their care plan does not even tell who is going to visit and when. In addition the DON agreed the Hospice services company did not adhere to their contract regarding the care plan and documentation.",2020-09-01
83,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,867,E,0,1,WJ7O11,"Based on facility record review, staff interview, and review of deficient practices identified during the survey, the facility failed to maintain an effective Quality Assurance Committee to develop and implement appropriate plans to correct identified quality deficiencies and coordinate the facility's required implementation of all regulatory changes. No attempts were made to correct nurses' failure to sign off narcotic counts at shift change after the pharmacist identified the concern. This has the potential to affect all residents residing in the facility. Facility census: 140. Findings include: a) On 07/31/19 at 4:31 PM, a review of the Controlled Substance Forms on the 200 hall with Licensed Practical Nurse (LPN) #143 revealed nurses failed to initial the sheets at the change of shift after controlled medications were counted. LPN #143, confirmed medication counts are to be completed between two (2) nurses at the change of shift and both nurses are to initial the forms. Further review at this time found incomplete Controlled Substance Forms on both medication carts on the 200 and 300 hall and the single cart located on the 100 hall. The Assistant Director of Nursing (ADON) acknowledged the Controlled Substance Forms were incomplete during an interview on 07/31/19 at 4:32 PM. On 08/05/19 at 9:52 AM, a review of the pharmacist's Controlled Substance Audit dated 02/08/19 with the ADON revealed the pharmacist identified missing signatures during a random audit of the change of shift count forms. On 08/05/19 at 3:17 PM, a review of the Quality Assurance & Performance Improvement Plan 2019 presented with the Quality Assurance & Performance Improvement (QAPI) policy revealed the facility did not address the incomplete controlled substance forms. An interview was conducted with the Administrator, the person in charge of Quality Assurance #136 and Corporate Consultant (CC) #154 on 08/05/19 at 3:30 PM. The Administrator and CC #154 confirmed they were unaware of results of the pharmacist's 02/08/19 findings of missing signatures during a random audit of the change of shift count forms. CC #154, acknowledged a plan was initiated on 08/01/19, after the survey team identified the concern.",2020-09-01
84,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,880,F,0,1,WJ7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy and procedure review, the facility failed to maintain an effective infection control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. Observation of pressure ulcer dressing changes revealed no use of a barrier, soiled dressing placed on an overbed table next to water pitcher and drinking glasses and failure to change gloves when going from the buttocks area to the residents back. During medication administration, residents medication was placed on the resident's overbed table without any type of barrier. In addition, the laundry room lacked separation between the clean and soiled areas to prevent cross contamination and failed to change contaminated gloves while changing a resident's tube feeding. Three (3) breakfast trays were found in the Nutrition room [ROOM NUMBER] hall after the lunch meal had been returned to the kitchen. One of the breakfast tray was from a resident who was on isolation precautions. This practice has the potential to affect more than a limited number of residents. Resident identifiers: #116, #76, #115, #101, #98. Facility census: 140. Findings included: a) Resident #116 On 07/30/19 at 10:22 AM observation of pressure ulcers dressing change with Licensed Practical Nurse (LPN) #1 revealed clean dressings were placed on the residents bed. b) Resident #76 On 07/31/19 at 10:52 AM observation of pressure ulcer dressing change by LPN #1 revealed there was no barrier placed on the overbed table or was the overbed bed cleaned prior to opening pressure ulcer dressings. The soiled dressing was placed on the overbed table next to the Resident #76 water pitcher and drinking cups. In addition, obtained marking pen from pocket, dated the dressing, and placed the pen back into pocket with contaminated gloves. c) Resident #115 Observation of a pressure ulcer dressing on 07/31/19 at 11:37 AM with LPN #1 revealed the coccyx area was cleaned and then the pressure ulcer on the back was cleaned without changing contaminated gloves. In addition, no barrier was used on the overbed table nor was a trash can and/or plastic bag used to dispose of soiled dressings and/or 4x4 (gauze pad) used to clean the pressure ulcers. On 08/05/19 at 12:45 PM a review of the facility policy titled Dressings, Dry/Clean found the following: 1. Clean bedside stand. Establish a clean field. 2. Place the clean equipment on the clean field. 3. Tape a biohazard or plastic bag on the bedside stand or use a waste basket below clean field. 7. Pull glove over dressing and discard into plastic or biohazard bag. 15. Cleanse the . Clean from the least contaminated area to the most contaminated area. 18. Discard disposable items into the designated container. The Director of Nursing (DON) and the Assistant DON - Infection Control Nurse (ICN) agreed the policy and procedure were not followed during the Pressure Ulcer dressing changes on the 08/05/19 at 12:45 PM. d) 300 Hall On 07/29/19 at 12:33 PM the three-hundred (300) hall observation of the three-hundred (300) with one breakfast tray (already used by resident), placed on the counter top. Licensed nurse (LPN) #143 explained the resident takes longer to eat and the tray would be sent to the kitchen with lunch trays, and agreed the tray should have been sent to the kitchen upon the resident completing the breakfast meal. Again on 07/30/19 at 12:45 PM the (300) hall nutrition room had three (3) breakfast trays (already used by resident), placed on the counter top with one of these trays belonging to a resident in isolation for, extended spectrum beta-lactamases (ESBL) infection in the urine. Licensed nurse #8 explained the kitchen should have been called to pick up the trays. e) Laundry room On 07/30/19 at 10:20 AM, an observation of the laundry area with Housekeeper #123 revealed one room with washing machines on one wall, dryers along the opposite wall and a large cart of bagged soiled linen sitting between the rows of machines. During this observation, Housekeeper #123 confirmed there was no separation between the clean and soiled laundry. The Infection Control Nurse/Assistant Director of Nursing confirmed the laundry room lacked separation to prevent cross contamination during an interview on 07/30/19 at 11:00 AM. f) Resident #98 - Tube feeding On 07/30/19 at 1:10 PM, Licensed Practical Nurse (LPN) #140, donned clean gloves and began preparing Resident (R) #98's tube feeding. LPN #140, filled two (2) feeding bags, one with tap water and the other with [MEDICATION NAME] 1.5. LPN #140 picked up the trash can with her gloved right hand, placed the can by the bedside, primed the feeding pump and feeding tubing and attached the feeding to R#98's gastric tube without changing her right glove. During an interview immediately following this observation. LPN #140 confirmed she contaminated her glove when she picked up the trash can and should have immediately changed it before proceeding. g) Resident #101 - Medication Administration An observation of medication administration, on 08/05/19 at 8:17 AM, revealed Registered Nurse (RN) #5 took pills from the medication cup and poured them onto Resident #101's bedside table without any kind of barrier or cleansing of the surface first. An interview with RN #5, on 08/05/19 at 8:19 AM revealed she stated I should have put down a barrier on the table. It is the only way he will take his pills.",2020-09-01
85,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,925,E,0,1,WJ7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain an effective pest control program so that the facility is free of pests. The facility failed to maintain a kitchen area that was free from bugs. The failed practice had the potential to affect an more than a limited number of residents. Facility census: 140. Findings included: a) Kitchen An observation, on 07/30/19 at 1:48 PM, revealed a brown shelled bug with antennas crawling on the kitchen wall above the steam tables. An immediate interview with Dietitian occurred and bug was pointed out to Dietitian. The Dietitian stated, Oh that stinks. The bug was not obtained off the wall and then disappeared to wander the kitchen. An observation on 07/30/19 at 4:11 PM, revealed approximately 12 gnats flying in the kitchen area. An interview with DC #126, on 07/30/19 at 4:13 PM, revealed the facility had a history of [REDACTED].#126 stated the bugs are coming in through the floor drain.",2020-09-01
86,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,947,D,0,1,WJ7O11,"Based on employee records and staff interview the facility failed to ensure continuing competence of nurse aides (CNA) included dementia management and abuse prevention training. Two (2) CNA's lacked dementia care and one (1) CNA lacked abuse prevention training as required. The failed practice affected two (2) of five (5) CNA's employed by the facility. Employee identifiers: #1 and #4. Facility census: 140. Findings included: a) Employee #1 An employee record review, on 08/06/19 at 8:39 AM, of CNA's in-service trainings was conducted. Employee #1 lacked training in the areas of Dementia Management and Abuse Prevention courses as required. An interview with ADoN, on 08/06/19 at 8:39 AM, revealed no other documentation availability for Employees #1 regarding in-service completion. ADoN stated, that is all the information for training we could find. b) Employee #4 An employee record review, on 08/06/19 at 8:39 AM, of CNA's in-service trainings was conducted. Employee #4 lacked training in the area of Dementia Management as required. An interview with ADoN, on 08/06/19 at 8:39 AM, revealed no other documentation availability for Employees #4 regarding in-service completion. ADoN stated, that is all the information for training we could find.",2020-09-01
100,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2018-08-23,679,D,0,1,TKSO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, observations and review of policy and procedure for activities, the facility failed to invite and provide activities of interests for two of three residents reviewed for activities. Resident identifiers: #74 and #80. Facility census: 176. Findings included: a) Resident #74 1. Resident #74's medical record was reviewed on 08/22/18 at 09:46 AM. The resident was admitted on [DATE]. The Admission Minimum Data Set (MDS) assessment Section I revealed the resident had [DIAGNOSES REDACTED]. Section G0110, required extensive assistance of two with transfers. Section F0500, Interview for Activity Preferences, responses from the resident were reviewed and revealed that is was very important to have books, newspaper or magazines to read, music, news, group activities, favorite activities, religion and fresh air. The resident's activities care plan, dated 05/15/18, was reviewed on 08/22/18 at 10:18 AM. The care plan revealed the resident had an anticipated short stay and had interventions that included the following: ensure that the activities the resident attend are compatible with known interests, invite the resident to activities, provide a program of activities that is of interest, provide activity calendars, review resident activation needs, staff will informally visit on a regular basis to ensure leisure needs are being met, the resident needs assistance/escort to activity functions, attending church services, when resident chooses not to participate in organized activities, the resident prefers to spend time in room listening to music or reading. Observations were made of the resident on 08/20/18 at 03:35 PM of the resident in bed and awake. The television that was in front of the bed was not on. On 08/21/18 at 12:12 PM the resident was observed lying in bed asleep. On 08/22/18 at 08:57 AM the resident was observed in bed and had just finished breakfast, at 10:58 AM the resident was asleep in bed. On 08/23/18 at 9:24 AM the resident was observed in bed in room awake, the television was not on and there was no music on. On 08/22/18 at 10:34 AM the Individual Activity Participation Records for May, June, (MONTH) and (MONTH) (YEAR) were reviewed. The documentation revealed in the past four months that Resident #74 only participated in music one time, cards/other games one time and received mail twice. The resident refused glamour nails once. There were no other refusals documented on the participation records. On 08/22/18 at 11:00 AM, Activity Assistant (AA)#21 was interviewed. AA #21 stated that she used to be the Activity Director but stepped down and was an Activity Assistant. AA #21 was asked if she invited Resident #74 to the group activities and she stated she had not invited the resident any this month. She stated she did not invite her to come to activities, realized she should and that was a mistake. She stated she made informal visits to Resident #74's room, but nothing specific based on her activity preferences. On 08/23/18 at 11:06 AM, Activity Assistant (AA) #22 was interviewed. AA #22 stated she provided activities on the unit. AA #22 stated she did not invite Resident #74 to come to activities when the resident was in bed. On 08/23/18 at 11:07 AM, Activity Director (AD) #80 was interviewed regarding Resident #74. AD #80 verified the staff did not provide invitations for the resident to attend scheduled activities based on the resident's individual activity preferences and should have. b) Resident #80 2. Resident #80's record review was reviewed on 08/21/18 at 03:51 PM. The Annual Minimum Data Set (MDS), dated [DATE], Section I had [DIAGNOSES REDACTED]. Section G0110 revealed the resident required extensive assistance of two for transfers and revealed in Section F0500, Interview for Activity Preferences, responses from the resident were as follows: very important to have music, news, pets, group activities, fresh air, favorite activities and religious activities. The Resident #80's care plan, dated 7/31/18, was reviewed on 08/21/18 at 04:03 PM. The care plan revealed the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs. The care plan interventions included: ensure that the activities the resident attend are compatible with known interests and preferences, compatible with individual needs and abilities, introduce the resident to residents with similar background and interests, invite the resident to scheduled activities, provide a program of activities that is of interest, provide activity calendars, resident needs assistance/escort to activity functions, when resident chooses not to participate in organized activities the resident prefers to sit up in wheelchair in hall and socialize among peers, watch television for social and sensory stimulation. Observations were made on 08/20/18 at 03:27 PM of the resident lying in bed awake. There was no television on the wall in front of the resident's bed. Only a television wall mount was there and no radio or music was playing. Observations were made on 08/21/18 at 12:11 PM of the resident lying in bed awake. There was no television on the wall mount and there was no radio or music playing. On 08/21/18 at 04:08 PM the Individual Activity Participation Records for June, (MONTH) and (MONTH) (YEAR) were reviewed. The documentation recorded on Individual Activity Participation Records revealed that Resident #80 attended cards/other games and a religious activity one time in (MONTH) (YEAR). Further review of the Individual Activity Participation Records dated June, (MONTH) and (MONTH) (YEAR) revealed documentation that the resident was provided television and visits with family or friends every day in June, (MONTH) and (MONTH) (YEAR). On 08/21/18 at 02:09 PM, Activity Assistant (AA) #160 was interviewed. AA #160 stated she had not invited the resident to any group activities. AA #160 verified the Individual Activity Participation Record for (MONTH) (YEAR) revealed television was provided to the resident every day. AA #160 stated the resident was independent with television and watched it in her room. AA#160 walked with this writer to the resident's room and verified the resident did not have a television in front of her bed that she could operate independently. Observations were made of the resident's roommate with a television, but the cubicle curtain was observed closed. AA #160 stated she didn't invite the resident to activities because she was in bed. AA #160 provided the resident's care plan and stated she goes by the care plan to provide activities to the resident but verified she didn't follow it. On 08/21/18 at 02:20 PM Resident Care Specialist (RCS) #91 was interviewed. RCS #91 stated the activity staff invite the resident to activities. RCS #91 stated Resident #80 couldn't get out of bed on her own and required assistance of two staff to get out of bed. RCS #91 stated the nursing staff or activity staff could assist to take the resident to the activity if the resident wanted to go. On 08/21/18 at 02:50 PM Activity Director (AD) #80 was interviewed. AD #80 verified on the Individual Activity Participation Records for the past three months the resident received visits with family or friends every day and was independent in watching television every day. AD #80 verified there was no television in the Resident #80's room. AD #80 verified there had been no radio in the resident's room until today and that music was listed as a preference of the resident on the care plan. AD #80 was not aware the resident had no visitors and had a caseworker listed as a primary contact person. On 08/21/18 at 03:32 PM Licensed Practical Nurse (LPN) #41 was interviewed. LPN #41 stated had not seen any family or friends visit and the resident's contact person was a caseworker that she had to call if there were concerns regarding the resident. On 08/23/18 at 11:06 AM Activity Assistant (AA) #22 was interviewed. AA #22 stated she provided activities on the unit but does not invite residents to come to group activities when the residents are still in bed. AA #22 verified she did not invite Resident #80 to join the scheduled activities on the unit per the care plan. On 08/23/18 at 11:07 AM, Activity Director (AD) #80 was interviewed regarding both Resident #74 and Resident #80. AD #80 verified that the activity staff failed to invite the resident to scheduled activities, failed to provide a television or music based on individual preferences of the resident. AD #80 also verified for both Resident #74 and #80 that if the residents were not up and out of bed, the Activity Assistants should still ask the resident if they wanted to come to activities. If the residents wanted to come, the Activity Assistants should inform the nursing staff to assist with getting the residents up so they could attend the activity. AD #80 verified if the nursing staff did not get the resident up out of bed when asked, it should be reported to her or nursing staff. AD #80 verified that if the resident did not want to get out of bed to attend a group activity, the activity assistants should provide things to do in their room based on the Individual Activity Preferences on the care plan. If the resident refused, it should be documented on the Individual Activity Participation Records as a refusal. AD #80 verified the staff did not follow the care plan to invite the residents to scheduled activities. AD #80 provided the Policy on Activities Program on 08/23/18 at 11:08 AM. The policy was reviewed and revealed that activities are provided to meet the assessment and interests of each resident. The resident's interests are assessed upon admission and according to the Resident Assessment Instrument (RAI) manual with MDS reference periods and a comprehensive care plan is developed and reviewed and revised as needed. AD #80 verified the policy wasn't followed to provide activities to Residents #74 and #80.",2020-09-01
101,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2018-08-23,695,D,0,1,TKSO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that one resident's oxygen therapy was monitored for the need and effectiveness of oxygen therapy and failed to document respiratory signs and symptoms, changes in oxygen administration, and/or results of oxygen therapy. This affected one of one resident reviewed for oxygen therapy in the sample of 28. Resident identifier: #92. Facility census: 176. Findings included: a) Resident #92 Resident #92's medical record was reviewed on 08/22/18 at 02:17 PM. Resident #92 is severely cognitively impaired according to the Minimum Data Assessment, dated 05/24/18. Resident #92 had [DIAGNOSES REDACTED]. Resident #92 had a physician's orders [REDACTED]. The order further stated that the oxygen should be titrated to keep oxygen levels above 92%. There were no oxygen saturation levels documented in the medical record. There were no progress notes regarding the resident's respiratory signs and symptoms, the time or reason oxygen was administered, or the result of oxygen therapy. Resident #92's care plan, target date 08/21/18, listed interventions to observe for signs and symptoms of acute respiratory insufficiency such as anxiety, confusion, restlessness, shortness of breath at rest, cyanosis, and somnolence. Resident #92 was observed in bed receiving oxygen therapy via nasal canula on 08/20/18 at 11:35 AM, 08/21/18 at 01:39 PM, 08/21/18 at 5:45 PM, and 08/22/18 at 10:10 AM at 2 L/M. On 08/22/18 at 02:49 PM Resident #92 was observed receiving oxygen at 3.5 L/M via the nasal canula. On 08/22/18 at 02:49 the Unit Coordinator/Licensed Practical Nurse (LPN) #55 confirmed that Resident #92's oxygen level was set at 3.5 L/M. LPN #55 stated that the order is for 2 L/M as needed, but that the oxygen can be titrated up to keep saturation levels greater than 92% per the physician's orders [REDACTED]. LPN #55 said, There should be oxygen saturation levels for her. LPN #55 obtained Resident #92's oxygen saturation level and reported it was 95 - 96%. On 08/22/18 at 03:01 PM LPN #75 was interviewed. LPN #75 confirmed that she was the nurse caring for Resident #92 on that day. LPN #75 said she checked Resident #92's oxygen concentrator a couple hours ago and it was on 2 L/M. LPN #75 said she checked Resident #92's oxygen saturation level at that time and it was 97%. LPN #75 said she did not record the result in the medical record. On 08/22/18 at 03:14 PM the Director of Nursing (DON) was interviewed. The DON said that oxygen saturation levels should be checked as needed depending on what symptoms the resident is displaying. The DON said, They should not put oxygen on her unless she is displaying signs and symptoms, or her saturation levels are below 92%. The facility's Oxygen Administration Policy, revised (MONTH) 2010, was reviewed on 08/22/18 at 03:30 PM. The policy stated in part, D[NAME]UMENTATION: In the Nurse's notes and Treatment Administration Record (TAR) and/or Medication Administration Record [REDACTED].",2020-09-01
102,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2018-08-23,698,D,0,1,TKSO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain effective communication with the [MEDICAL TREATMENT] center and failed to follow-up on communication related to the resident's blood pressure dropping during [MEDICAL TREATMENT]. This affected one of one resident reviewed for [MEDICAL TREATMENT] care in the sample of 28. Resident identifier: #32. Facility census: 176. Findings included: a) Resident #32 On 08/20/18 at 10:39 AM Resident #32 was interviewed in his room. Resident #32 stated that sometimes his blood pressure is low during [MEDICAL TREATMENT] and that he was instructed by the [MEDICAL TREATMENT] clinic not to take his morning blood pressure medication before [MEDICAL TREATMENT]. Resident #32 said he leaves for [MEDICAL TREATMENT] around 06:00 AM and he takes his morning medications before he leaves, but was under the impression that he was not getting his blood pressure medication before he goes to [MEDICAL TREATMENT]. On 08/21/18 at 03:55 PM Resident #32's medical record was reviewed. Resident #32 has intact cognition according to the Minimum Data Sets (MDS), dated [DATE]. Resident #32 had [DIAGNOSES REDACTED]. Resident #32 received [MEDICAL TREATMENT] every Tuesday, Thursday and Saturday, according to the current [MEDICAL TREATMENT] care plan, initiated 05/24/18. The care plan intervention stated, [MEDICAL TREATMENT] Communication Record is sent to the [MEDICAL TREATMENT] center with each appointment and return of form is ensured after appointment is completed. Resident #32 had physician's orders [REDACTED]. [REDACTED]. Resident #32 was scheduled to receive his first doses of [MEDICATION NAME] and [MEDICATION NAME] ER at 0600 (06:00 AM) according to the Medication Administration Record (MAR), dated 08/01/2018 - 08/31/18. Resident #32's progress note, dated 08/5/18, 06:29 read, RES STATED THAT [MEDICAL TREATMENT] NURSE STATES HIS BP IS DROPPING TOO LOW AND NOT TO TAKE HIS BP MEDS PRIOR TO [MEDICAL TREATMENT]. HELD BP MEDS, INFORMED SUPERVISOR AND SIALYSIS PER PROGRESS NOTE. SENT ORDER SHEET W/RES TO [MEDICAL TREATMENT] FOR ORDERS TO BE WRITTEN REGARDING BP MEDS. The progress note was signed by Licensed Practical Nurse (LPN) #70. Resident #32's corresponding [MEDICAL TREATMENT] Communication Record form (Briggs), dated 08/05/18, and completed by LPN #70 read, Res stated that you wanted his blood pressure meds held prior to [MEDICAL TREATMENT]. [MEDICATION NAME] and [MEDICATION NAME] held today. We can change time of BP meds if needed. Pls respond below. There was no response documented from the [MEDICAL TREATMENT] center on the 08/05/18 [MEDICAL TREATMENT] Communication form. The only information completed on the form by the [MEDICAL TREATMENT] center was the resident's pre- and post-[MEDICAL TREATMENT] weights. The following sections where left blank: [MEDICAL TREATMENT] completed without incident?; Problem with access graft/catheter?; Lab work completed?; Medications given at [MEDICAL TREATMENT]; Recommendations/Follow-up. Resident #32's MAR and progress notes were reviewed on 08/23/18 at 10:00 AM. There was no follow-up regarding whether Resident #32's blood pressure medication should be held prior to [MEDICAL TREATMENT] according to review of the progress notes dated 08/05 - 08/23/18 in the medical record. Resident #32's pre-[MEDICAL TREATMENT] blood pressure medications, [MEDICATION NAME] and [MEDICATION NAME] ER, were held on 08/05/18 due to the resident self-report of his blood pressure dropping during [MEDICAL TREATMENT], per documentation in the MAR and progress note dated 08/05/18. Resident #32's blood pressure medications were also held on 08/09/18 and 08/11/18 due to the resident's refusal per documentation in the MAR. Resident #32 received his blood pressure medications on all other pre-[MEDICAL TREATMENT] days including 08/07, 08/14, 08/16, 08/18, 08/21, and 08/23/18 per the MAR. On 08/23/18 at 10:05 AM Registered Nurse (RN) #34 confirmed there was no follow-up documented regarding the 08/05/18 communication to the [MEDICAL TREATMENT] center about the resident's blood pressure medication. RN #34 said Resident #32 continued to receive his blood pressure medications prior to [MEDICAL TREATMENT]. There were no [MEDICAL TREATMENT] Communication Record forms for Resident #32's [MEDICAL TREATMENT] visits of 08/11/18, 08/14/18, and 08/16/18. Resident #32's [MEDICAL TREATMENT] Communication Record forms dated 08/02/18 and 08/21/18 were also incomplete in the section to be completed by the [MEDICAL TREATMENT] center. An interview was conducted with the Director of Nursing (DON) on 08/21/18 at 04:09 PM. The DON stated the nurse should verify that the [MEDICAL TREATMENT] Communication form is completed upon the resident's return to the facility. The DON said if it's not completed they should fax it back to the [MEDICAL TREATMENT] center and request that it be completed. The DON also stated that if the [MEDICAL TREATMENT] center does not send back the [MEDICAL TREATMENT] Communication form the nurse should call the [MEDICAL TREATMENT] center and request the form. The DON confirmed that the [MEDICAL TREATMENT] Communication Record forms for 08/11/18, 08/14/18 and 08/16/18 were not in the record or in the facility. The facility policy titled [MEDICAL TREATMENT], Care of Residents, revised (MONTH) (YEAR), stated in part, 3. A [MEDICAL TREATMENT] Communication Record (Briggs) is initiated and sent to the [MEDICAL TREATMENT] center for each appointment. Ensure it is received upon return.",2020-09-01
103,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2018-08-23,756,D,0,1,TKSO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and Consultant Pharmacist interviews, the facility failed to ensure that the consulting pharmacist identified drug irregularities related to laboratory (lab) testing levels for one of seven sampled who were reviewed for unnecessary medications. Resident identifier: #84. Facility census: 176. Findings included: a) Resident #84 A review of the admission record for Resident #84 was conducted on 08/22/18 at approximately 4:52 PM. The admission record revealed that Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's policy and procedure entitled Monthly Drug Regimen Review, dated (MONTH) (YEAR), was reviewed on 08/24/18 at approximately 10:45 AM. The policy read in part, The facility contracts with a pharmacist to perform a monthly review of each resident's drug regimen to ensure the necessity and safety of each prescribed medication. Under the section entitled procedure the following entries were noted in part: --The pharmacist reviews resident charts monthly and submits a written report of the irregularities to the attending physician, the Director of Nursing and the facility Medical Director. --The pharmacist's report includes resident' names, relevant drug(s) and identified irregularity(ies). A review of the physician's orders [REDACTED]. The order summary note indicated that Resident #84 was scheduled to have a HgbA1C (a measure of average blood sugar over the past 3 months) every 3 three months d/t (due to) DM (Diabetes Mellitus) - Due (MONTH) (YEAR). Upon further review it was determined that the HgbA1C lab results were not found in the clinical record. An interview was conducted with nurse #28 on 08/22/18 at approximately 4:52 PM regarding the missing HgbA1C level for the month of (MONTH) (YEAR). Nurse #28 stated, It's not in the lab book and the lab doesn't have it in their records either. Nurse #28 shared that she had looked in the both the clinical record and well as the South unit's lab (laboratory) book. She explained that the lab book maintains labs that need to be drawn daily. Nurse #28 stated that she had called the lab to see if they had the lab results in their database, but there was no record of the HgbA1C. A review of the admission MDS (Minimum Data Set) assessment was conducted on 08/22/18 at 4:59 PM. The MDS assessment was dated 04/27/18 and had the resident coded as having a [DIAGNOSES REDACTED]. The MDS assessment also indicated that the resident had received insulin injections on 6 occasions within the last 7 days. An interview was conducted with the DON (Director of Nursing) regarding the missing HgbA1C level on 8/22/18 at 5:07 PM. The DON said she would follow-up on the missing HgbA1C level. An interview was conducted with the Consultant Pharmacist (#167) via telephone call on 08/23/18 at 10:32 AM. The DON was present for the call. The Consultant Pharmacist was asked about the monthly drug regimen review for the month of (MONTH) (YEAR) which failed to note the missing HgbA1C that was ordered for the month of (MONTH) (YEAR). The Consultant Pharmacist stated that she was driving at the time of the call and did not have immediate access to her records. The pharmacist went on to explain her process stating that if a lab were missing, she would give the nurses a piece of paper with what she needed to see if it was something they could find immediately. This writer informed the Consultant Pharmacist that the medication regimen review form completed by her for the months of (MONTH) and (MONTH) (YEAR) both indicated that there were no irregularities as evidenced by an X which was placed in the box indicating no irregularities. The box on the same form next to See report for any noted irregularities and or recommendations was left blank. The Consultant Pharmacist #167 stated that she would not necessarily have written a recommendation at that point. She went on to say that when she reviewed the chart again in (MONTH) of (YEAR) and the lab was still missing she would make a written recommendation at that point. As the Consultant Pharmacist was driving at the time of this interview, this writer encouraged her to call back to the facility on ce she had an opportunity to review her records. No further follow-up was provided by the Consultant Pharmacist. The concern regarding the HgbA1C was shared with the administrator on 08/23/18 at approximately 11:10 AM. The administrator acknowledged being aware of the drug irregularity.",2020-09-01
104,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2018-08-23,760,D,0,1,TKSO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, resident and staff interviews, the facility failed to prevent a significant medication error from occurring for one of 12 sampled residents (Resident #120) who was reviewed for medication administration. Resident #120 was administered long acting insulin that was prescribed for another resident. Resident identifier: #120. Facility census: 176. Findings included: a) Resident #120 An interview was conducted with Resident #120 on 08/20/18 at 11:05 AM. Resident #120 stated that a male nurse (Nurse #4), who she referred to as the medicine man had administered insulin to her in her belly (abdomen) although she is not diabetic. She repeated this again stating that, He gave me an insulin needle in my belly. She also stated that Nurse #4 had administered the insulin injection on the day prior to this interview which was Sunday, 08/19/18. Resident #120 went on to say that she had specifically asked Nurse #4 why was she receiving the insulin injection as she was not diabetic. Resident #120 reported that Nurse #4 gave her the insulin injection anyway and stated, Well, you're supposed to get it. Resident #120 also stated that Nurse #4 checked her blood sugar level after he had administered the insulin injection. She said he told her that the blood sugar reading was 108 and showed it to her on the blood sugar monitor. Resident #120 said that Nurse #4 told her it was fine. Resident #120 stated that Nurse #4 did not check her blood sugar level before administering the insulin injection. Additionally, Resident #120 voiced that she did not report the insulin administration incident to any other facility staff but said she did call her family member and informed him of the incident on the same day that the incident occurred, Sunday, 08/19/18. A review of the clinical record was conducted for Resident #120 on 08/20/18 at approximately 12:05 PM. The admission record, which listed the resident's diagnoses, indicated that Resident #120 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Neither the admission record nor any other part of the clinical record indicated that Resident #120 had a [DIAGNOSES REDACTED].#120 and failed to indicate that Resident #120 had a physician's orders [REDACTED]. A review of the admission MDS (Minimum Data Set) assessment was conducted on 08/20/18 at approximately 12:35 AM. The MDS, dated [DATE], had the resident coded as having a BIMS (Brief Interview for Mental Status) summary score of 15 indicating the resident's cognition was intact. Resident #120 was also coded as being oriented to year, month and date as well. Resident #120 was not coded as having a [DIAGNOSES REDACTED]. An interview was conducted with the Unit Manager, Nurse (#34) on 08/20/18 at approximately 12:50 PM. Nurse #34 stated that she was aware of the allegation involving the insulin error as Resident #120's family member came in earlier that morning before lunch and brought it to her attention. Nurse #34 confirmed that Resident #120 did not have a physician's orders [REDACTED]. Nurse #34 also reviewed the daily staffing report with this writer and confirmed that Nurse #4 was on duty the previous day when Resident #120 alleged having received an insulin injection. Nurse #34 also conveyed that Nurse #4 is a PRN (works as necessary) nurse and worked from 7AM -7PM on 08/19/18. Nurse #34 stated that another nurse, Nurse #113 was the unit manager that was on duty at the time of the insulin administration error and that Nurse #113 typically worked a double shift on the weekends from 7AM-11:30 PM. Initial attempts to call Nurse #4 and Nurse #113 were unsuccessful. Voicemail messages were left for each of these nurses. An interview was later conducted with Nurse #4 on 08/20/18 at 3:21 PM. Nurse #4 stated that he came back to the facility at the request of the Director of Nursing (DON). Nurse #4 stated, If you're asking about the insulin, yes, I made a mistake. I'll own up to it. I was supposed to give it to a resident across the hall. This is only the second time that I worked down there (referring to the hallway where Resident #120 resides.) I only have the computer to go by. I don't really know the people. I just made a mistake. Nurse #4 stated, As soon as I gave it to her (Resident#120) she said, But I'm not a diabetic. Why am I getting insulin? Nurse #4 stated that he had administered 30 units of [MEDICATION NAME]to Resident #120. Nurse #4 stated, I went by the name and the picture on the MAR (Medication Administration Record) when asked which identifiers were used to correctly identify Resident #120 as the correct resident to receive the 30 units of [MEDICATION NAME] insulin. Nurse #4 also stated, They are very similar referring to the appearance of Resident #120 and the other resident across the hall who he said was supposed to receive the insulin. Nurse #4 stated, I'm sick to death over it. I've never done anything like this before. During the same interview with Nurse #4 he stated that he knew right away that he had made a mistake and immediately reported the incident to his unit manager (Nurse #113). Nurse #4 shared that he did not call the physician after the incident, but that his unit manager, Nurse #113, had done so. He also stated that Nurse #113 gave him instructions to check Resident #120's blood sugar level three more times as ordered by the physician. Nurse #4 stated that he checked Resident #120's blood sugar levels at least three more times after administering the insulin. Nurse #4 recalled checking Resident #120's blood sugar immediately after administering the insulin and received 108. He acknowledged showing the blood sugar monitor result to Resident #120. He also reported checking the resident's blood sugar level again after lunch which was 103, before dinner, which was 93 and again after dinner around 5:30 PM. At 5:30 PM he stated that the resident's blood sugar level was 91. Nurse #4 voiced that he had written an incident report and pinned it up on the incident board before leaving work. He also recalled reporting the incident to the oncoming nurse that worked the 7PM-7AM shift. An interview was conducted with Nurse #113 on 08/20/18 at approximately 3:38 PM who confirmed that she was on duty at the time of the alleged insulin incident. She stated she worked from 7 AM - 2 AM on Sunday, 08/19/18. Nurse #113 recalled that Nurse #4 came to the desk and informed her that he had administered 30 units of [MEDICATION NAME]to the wrong resident. Nurse #113 also recalled Nurse #4 having notified Resident #120 that he had mistakenly given her insulin that was meant for another resident. Nurse #113 confirmed that she called the physician and notified the physician of the medication error that had occurred with Resident #120. She said she informed the physician that Resident #120 received 30 units of [MEDICATION NAME]and that Resident #120 was not diabetic. Nurse #113 also stated that the physician gave her an order to monitor Resident #120's blood sugar level three more times. Nurse #113 shared with this writer that the peak time for [MEDICATION NAME]was eight hours and Resident #120's blood sugar level never dropped below 91. Nurse #113 also stated that she went down to the room of Resident #120 after the incident had occurred and that Resident #120 reiterated the same story to her that Nurse #4 had previously communicated to her about the insulin error. Nurse #113 also stated that Nurse #4 had apologized to Resident #120. Nurse #113 stated that both she and Nurse #4 were very open with Resident #120 about the incident and that Resident #120 was aware of the incident and what had occurred. Nurse #113 also stated that Resident #120 had eaten all her meals that day and that she was fine (without symptoms of a low blood sugar reaction). Nurse #113 conveyed that nurses are supposed identify residents by checking the name on door check their arm bands and using the pictures on the MAR. Nurse #113 stated, Had Nurse #4 done that, yes, he should have known that it wasn't the right resident. Resident #120 was re-interviewed on 08/20/18 at approximately 4:22 PM to clarify if Nurse # 4 had checked her blood sugar before he administered the insulin. Resident #120 was quite certain that Nurse #4 did not check her blood sugar before giving her the insulin injection. The incident/accident report was reviewed on 08/22/18 at approximately 4:45 PM. The report conveyed that [MEDICATION NAME] 30 units was given in error on 08/19/18. The report also indicated that the physician was notified. Under the section entitled action the report indicated that the blood sugar level was checked immediately, and that snacks were also offered. The incident report also listed blood sugar checks that were conducted at the following times on 08/19/18: 10:00 AM-BS=108 11:00 AM -BS =103 1:30 PM -BS =93 5:00 PM- BS =91 The incident report was signed by Nurse#4 as having prepared the report and was also signed by the DON. The incident report indicated that the physician, unit manager (Nurse #113) and Resident #120 were each notified that [MEDICATION NAME] 30 units was given in error. The medication variance report was also reviewed on 08/22/18 at approximately 4:58 PM. The variance report indicated that [MEDICATION NAME] 30 units SQ (subcutaneous) was given in error and the error type was listed as wrong resident. An interview was conducted with the DON on 08/20/18 at approximately 4:30 PM. The DON stated that she was aware of the medication error involving both Resident #120 and Nurse #4. The DON shared that the incident report was completed before she arrived to work on the morning of 08/20/18. She conveyed that someone slid the incident report and the medication variance report under the door to her office over the weekend. The DON also stated that it was her expectation that the nursing staff use two resident identifiers to correctly identify their residents during medication pass. A review of the facility's policy regarding safe medication practices was reviewed and was dated (MONTH) 17, (YEAR). The policy indicated the following: To promote a culture of safety and prevent medication errors, nurses must adhere to the rights of medication administration: --Identify the right resident by using at least two resident identifiers. --Select the right medication --Give the right dose --Give the right medication at the right time --Give the medication by the right route --Provide the right documentation Under the section entitled Implementation the policy also indicated in part, confirm the resident's identity using as least two resident identifiers.",2020-09-01
105,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2018-08-23,773,D,0,1,TKSO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure two of seven residents reviewed for unnecessary medications obtained laboratory services as ordered by the physician. Resident identifiers: #84 and #93. Facility census: 176. Findings included: a) Resident #93 Resident #93 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the admission physician's orders dated 01/23/18, was conducted on 08/22/18 at 2:30 PM and revealed an order for [REDACTED].#93 to have his vitamin D level monitored every 6 months. The physician's orders documented the vitamin D level was to be performed in (MONTH) (YEAR). Further review of the clinical record revealed there was no evidence Resident 93's laboratory test for a vitamin D level was obtained in (MONTH) (YEAR). Interview with Licensed Practical Nurse (LPN) #170 on 08/22/18 at 2:18 PM revealed they were not able to find the physician ordered Vitamin D laboratory test results from (MONTH) (YEAR). A call was made to the laboratory responsible for conducting the test and the facility was informed the Vitamin D laboratory test for Resident #93's had never been completed. Staff #170 stated they were unsure of why Resident #93 failed to have the ordered laboratory testing to monitor his vitamin D level. During an interview with LPN Staff #170 again on 08/23/18 at 8:48 AM at the 400 nurses station revealed they had done more research but were still not able to determine why the vitamin D level was not obtained for Resident #93. Staff #170 stated the process for obtaining laboratory tests is the order for the test is obtained and the information is relayed to the laboratory for them to collect the blood sample. He verified Resident #93 was admitted to the facility with an order for [REDACTED]. During an interview with the Director of Nursing and the Administrator on 08/23/18 at 10:35 AM, they both verified Resident #93 failed to have his vitamin D laboratory test completed according to his current physician orders. Review of the facility policy for Diagnostic Testing on 08/23/18 at 10:30 AM revealed the policy was dated 11/17. The policy documented laboratory services provided must be both accurate and timely. Timely means that the tests are completed, and results are provided to the facility within timeframe's normal for appropriate intervention. The facility is responsible for quality and timely services whether services are provided by the facility or an outside agency. b) Resident #84 A review of the admission record for resident #84 was conducted on 08/22/18 at approximately 4:52 PM. The admission record revealed that Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders for Resident #84 was conducted on 08/22/18 at approximately 4:52 PM. The order summary noted that Resident #84 was scheduled to have a HgbA1C (a measure of average blood sugar over the past 3 months) every three months d/t (due to) DM (Diabetes Mellitus)-Due (MONTH) (YEAR). Upon further review, it was determined that the HgbA1C laboratory (lab) results were not located in the clinical record. An interview was conducted with nurse #28 on 08/22/18 at approximately 4:52 PM regarding the missing HgbA1C level for the month of (MONTH) (YEAR). Nurse #28 stated, It's not in the lab book and the lab doesn't have it in their records either. Nurse #28 shared that she had looked in the both the clinical record and well as the South unit's lab book. She explained that the lab book maintains labs that need to be drawn daily. Nurse #28 stated that she had also called the lab to see if they had the lab in their database, but there was no record of the HgbA1C. A review of the MDS (Minimum Data Set) assessment was conducted on 08/22/18 at 4:59 PM. The MDS assessment, dated 04/27/18, had the resident coded as having a [DIAGNOSES REDACTED]. The MDS assessment also indicated that the resident had received insulin injections on six occasions within the last seven days. An interview was conducted with the Director of Nursing (DON) regarding the missing HgbA1C level on 08/22/18 at 5:07 PM. The DON said she would follow-up on the missing HgbA1C level. A review of the facility's policy entitled Diagnostic Services Management, dated (MONTH) (YEAR), was reviewed on 08/24/18 at approximately 10:30 AM. The policy read in in part, Residents requiring laboratory, radiology or other diagnostic services will receive accurate and timely testing services from certified diagnostic facilities in accordance with Federal regulations to support [DIAGNOSES REDACTED]. The facility is responsible for quality and timely services whether services are provided by the facility or an outside agency.",2020-09-01
106,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2018-08-23,880,D,0,1,TKSO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed ensure that staff properly changed gloves and performed hand hygiene during personal care to maintain good infection control practices and failed to ensure the urine drainage bag was positioned properly so that it did not touch the floor. This affected one of two residents reviewed for urinary catheter in the sample of 28 residents. Resident identifier: #92. Facility census: 176. Findings included: a) Resident #92 Resident #92's medical record was reviewed on 08/22/18 at 02:17 PM. Resident #92 is severely cognitively impaired according to the Minimum Data Assessment, dated 05/24/18. Resident #92 has multiple [DIAGNOSES REDACTED]. Resident #92 had a physician's orders [REDACTED]. On 8/22/18 at 10:10 AM Certified Nursing Assistant (CNA) #44 was observed providing peri care to Resident #92. After gathering the care supplies, CNA #44 washed her hands and applied gloves prior to starting peri care. As CNA #44 was cleansing the peri area, she removed a small amount of feces using the washcloth. Each time she cleansed the peri area, which was four times, she touched the feces soiled washcloth with gloved hands. After completing peri care CNA #44 did not change her gloves. CNA #44 then touched the resident's gown, arms, legs, hands, pillows, back of the resident's head, and bed control mechanism while still wearing the same feces contaminated gloves. CNA #44 was interviewed afterwards and said that she should have changed her gloves after the peri care was complete. On 08/20/18 at 11:34 AM, 03:57 PM, on 08/21/18 at 01:38 PM and on 08/22/18 at 08:44 AM, the Resident #92's urine catheter bag was in contact with the floor. Resident #92's bed was in the low position and the catheter bag was hooked to the bed frame. The bottom of the urine catheter bag was in direct contact with the floor. On 08/22/18 at 08:44 AM Unit Manager/Licensed Practical Nurse (LPN) #55 confirmed that the urine catheter bag was in contact with the floor. LPN #55 said the bag should not be touching the floor. The facility policy titled Indwelling urinary catheter (Foley) care and management, revised 11/17/17, stated in part, Keep the drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder .However, don't place the drainage bag on the floor to reduce the risk of contamination and subsequent CAUTI (Catheter Acquired Urinary Tract Infection). The facility policy titled Hand Hygiene, revised 05/18/18, stated in part, The hands are the conduits for almost every transfer of potential pathogens form on patient to another, form a contaminated object to a patient, and from a staff member to a patient. Hand hygiene, therefore, is the single most important procedure in preventing infection.",2020-09-01
107,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,152,D,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility staff failed to identify the appointed Health Care Surrogate (HCS) for Resident #84, as designated by the attending physician on 06/05/17. Thus, the designated HCS was unable to exercise the resident rights to the extent provided by state law. Resident identifier: #84. Facility census: 180. Findings include: a) Resident #84 Review of Resident #84's medical records, on 08/30/17 at 11:15 a.m., found the resident was admitted to the facility on [DATE] following a hospitalization . Admission paperwork was completed by the resident's daughter. Further review found a HCS selection form completed 06/05/17, by the attending physician, designating the son as the HCS. No further HCS designation forms could be located in the medical records. Interview with Employee #122, social worker (SW), on 09/06/17 at 9:15 a.m., revealed she thought the daughter was the HCS on admission and had asked to appoint her brother the HCS due to personal issues. When asked, Is there another HCS designation form. She replied, I don't see any in the medical records. On 09/06/17 at 11:00 a.m., Employee #122, SW, provided a HCS designation form dated 05/30/17. She further confirmed this form had been faxed to her on 09/06/17 at 10:35 a.m. This HCS form indicated the Daughter was in fact appointed as the HCS while the resident was in the hospital. However, this HCS became void when the attending physician at the facility appointed Resident #84's son as the HCS on 06/05/17. The facility continued to notify Resident #84's daughter of changes in her condition and had the daughter listed as the health care decision maker on the resident face sheet even after Resident #84's son was appointed HCS on 06/05/17. On 09/07/17 at 10:25 a.m., the Director of Nursing (DON) and the Nursing Home Administrator (NHA) was both notified. No further information was provided.",2020-09-01
108,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,157,E,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the resident, physician, and/or resident responsible party when a significant change occurred in the residents condition. This deficient practice affected two (2) of twenty-nine (29) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). For Resident #84, the facility staff failed to notify the appropriate Health Care Surrogate(HCS) after 06/05/17, when a new HCS was appointed. Resident #19's responsible party was not notified when there was a change in her medication regimen. Resident identifiers: #84 and #19. Facility census: 180 Findings include: a) Resident #84 Review of Resident #84's medical records, on 08/30/17 at 11:15 a.m., found the resident was admitted to the facility on [DATE] following a hospitalization . Admission paperwork was completed by the resident's daughter. Further review found a HCS selection form completed 06/05/17, by the attending physician, designating the son as the HCS. No further HCS designation forms could be located in the medical records. Interview with Employee #122, social worker (SW), on 09/06/17 at 9:15 a.m., revealed she thought the daughter was the HCS on admission and had asked to appoint her brother the HCS due to personal issues. When asked, Is there another HCS designation form. She replied, I don't see any in the medical records. On 09/06/17 at 11:00 a.m., Employee #122, SW, provided a HCS designation form dated 05/30/17. She further confirmed this form had been faxed to her on 09/06/17 at 10:35 a.m. This HCS form indicated the Daughter was in fact appointed as the HCS while the resident was in the hospital. However, this HCS became void when the attending physician at the facility appointed Resident #84's son as the HCS on 06/05/17. The facility continued to notify Resident #84's daughter of changes in her condition and had the daughter listed as the health care decision maker on the resident face sheet even after Resident #84's son was appointed HCS on 06/05/17. On 09/07/17 at 10:25 a.m., the Director of Nursing (DON) and the Nursing Home Administrator (NHA) was both notified. No further information was provided. b) Resident #19 Record review found the physician reduced the resident's [MEDICATION NAME] on 07/14/17 from 2 milligrams (mg's), give 0.5 tablet by mouth, every 6 hours to [MEDICATION NAME] 1.5 mg's, give 0.5 mg. tablet three times a day for increased agitation, yelling, cursing, secondary to anxiety. At 4:07 p.m. on 09/06/17, the Director of Nursing (DON) said the facility had a blanket consent to increase and decrease the resident's [MEDICATION NAME]. The DON provided a copy of a psychoactive medication consent for [MEDICATION NAME]. The consent was signed by facility staff indicating verbal consent was obtained from the responsible party on 11/25/16 to use the antianxiety medication, [MEDICATION NAME]. On the consent form was a hand written notation, MD (physician) may (symbol for increase) or (symbol for decrease) PRN (as needed). The regulations require notification of the responsible party with each need to alter treatment. The DON confirmed she had no verification the responsible party was made aware of the decrease in the resident's [MEDICATION NAME] on 07/14/17.",2020-09-01
109,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,159,E,0,1,QLZ111,"Based on review of the resident's personal funds accounts and staff interview, the facility failed to notify each resident that receives Medicaid benefits when the amount in the resident ' s account reaches $200 less than the SSI resource limit for one person ($2,000). This deficient practice affected five (5) of ninety (90) residents that have personal funds managed by the facility. Resident identifiers: #307, #286, #256, #229, #224. Facility census: 180. Findings include: a) Residents Personal Funds Account: Review of residents' personal funds account, on 09/06/17 at 2:25 p.m., found five (5) residents had personal funds within $200.00 dollars of the $2,000.00 dollar limit allowed for residents receiving Medicaid benefits. Review of resident individual account balances for 08/06/17 found the following residents within $200.00 dollars of the $2,000.00 dollar limits: --Resident #307- $1,802.10 --Resident #286- $1980.45 --Resident #256- $2,204.38 --Resident #229- $1,907.79 Further review of resident individual account balances for 09/05/17 found the following residents within $200.00 dollars of the $2,000.00 dollar limits: --Resident #224- $2,103.15 --Resident #229- $2,209.79 Upon interview on 09/07/17, at 9:20 a.m., with the Business Office Manager (BOM), she found the computer generated notice when the resident's personal funds reaches $1,800.00 dollar limit. She further confirmed she was unaware she was to provide the notice to the residents and/or responsible party until the corporate offices informed her of the responsibility of printing and providing the resident and/or the responsible party today (09/07/17). On 09/07/17 at 10:25 a.m., the Director of Nursing (DON) and the Nursing Home Administrator (NHA) was both notified. No further information was provided.",2020-09-01
110,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,160,D,0,1,QLZ111,"**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 three (3) residents reviewed for the care area of personal funds during Stage 2 of the Quality Indicator Survey (QIS), had her/his personal funds conveyed within 30 days of death to the individual or probate jurisdiction administering the resident's estate. Resident identifier: # 382. Facility census: 180. Findings include: a) Resident #382. Medical records found Resident # 382 expired on [DATE]. On [DATE], a check for the amount of $1,144.03 dollars was made out to Resident #382 and mailed to the family. At 9:20 a.m., on [DATE]. Business Office Manager (BOM) confirmed the personal funds of Resident #382 was not conveyed to the proper individual or probate jurisdiction administering the residents' estate after her death. On [DATE] at 10:25 a.m., the Director of Nursing (DON) and the Nursing Home Administrator (NHA) was both notified. No further information was provided.",2020-09-01
111,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,161,E,0,1,QLZ111,"Based on record review and staff interviews, the facility failed to ensure a surety bond was in place in the amount to assure the security of all personal funds of residents deposited with the facility. Specifically, the surety bond that was purchased by the facility was not sufficient to cover the amount of deposits made by the residents in the facility. This practice had the potential to affect all 90 residents who have their money managed by the facility. Facility census: 180. The findings included: a) Record Review On 09/06/17 at 1:47 p.m., a review of the facility accounting records revealed that the personal needs funds on deposit with the facility totaled on the following dates: --04/03/17 - $77,144.71 --06/02/17 - $80,504.19 --07/03/17 - $73,506.75 --07/06/17 - $64,187.41 --07/10/17 - $62,240.07 The current resident fund surety bond in effect, issued 7/1/17, for the amount of $61,000. b) Staff Interview The Business Office Manager (BOM) was interviewed on 09/07/17 at 9:20 a.m. She confirmed that the current surety bond of $61,000 dollars is less than the amount deposited in the personal needs account. On 09/07/17 at 10:25 a.m., the Director of Nursing (DON) and the Nursing Home Administrator (NHA) was both notified. No further information was provided.",2020-09-01
112,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,225,E,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview the facility failed to thoroughly investigate the background of potential employees prior to or upon their employment at the facility. This was true for Employee # 150 who was hired by the facility on 04/10/17. As of 08/30/17 the facility had not screened Employee #150 through the West Virginia Cares Registry and Employment Screening (WV CARES) program as required by West Virginia State Code 16-49-9. This employee had access to all residents residing at the facility. Also, the facility failed to report three (3) of thirty-five (35) reportable incidents to the appropriate state agency. The facility reported these allegations to the Nursing Home Program even though a nurse aide was identified during the investigation as the alleged perpetrator therefore the allegations should have been reported to the Nurse Aide Program. These reportable incidents involved Resident #322, #372, and #280. Additionally, the facility failed to report all allegations of abuse and/or neglect to the appropriate state agencies for four (4) of fifty-five (55) complaints/concerns completed by the facility for the month of (MONTH) (YEAR). The allegations not reported involved Resident # 84, #110, #233, and #290. Finally, the facility failed to report a verbal allegation of neglect to the appropriate state agency for resident #367. Resident Identifiers: #84, #110, #233, #290, #322. #372, #280 and #367. Employee Identifier: #150. Facility Census: 180. Findings Include: a) WV CARES West Virginia Code 16-49-9 established new criminal background check requirements for applicants for employment as direct access personnel in long-term care facilities. Effective 08/01/15, all nursing home facilities were required to .prescreen all direct access personnel applicants considered for hire for negative findings by way of an Internet search of registries and licensure databases through the WV Cares website. WV CARES is administered by the Department of Health and Human Resources and the WV State Police Criminal Investigation Bureau (CIB) in consultation with the Centers for Medicare and Medicaid Services (CMS), the Department of Justice (DOJ) and the Federal Bureau of Investigation (FBI). The program uses web-based technologies to provide employers a single portal for checking state and national abuse registries and the state and national sex offender registries. The web-based system also provides employers access to Nurse Aide Registries for all 50 states and professional licensure registries where available. The web based system provides an efficient and effective means for an employer to check an applicant's status prior to paying the cost of a criminal history background check. Through fingerprinting, this program provides a comprehensive criminal history records search of national and state criminal history records that was not available under the previous reliance on name-based record searches. The program relies on new technology to monitor criminal histories and alert officials when a subsequent change in criminal history occurs (i.e., rapback) A monitored criminal history record means the cost of re-fingerprinting is not required for employees who change employers in this industry (or apply for work at more than one employer) within the timeframe of a valid background check. All fitness determinations will be performed by WV CARES who have cleared state and federal background check requirements. Employers will receive a notice of the applicants employment eligibility once the fingerprint based background check results are received. At 8:48 a.m. on 08/30/17 a Notification of Eligible Fitness Determination letter from WV Cares was requested for Employee #150 who was hired in the dietary department on 04/10/17. At 11:47 a.m. on 08/30/17 Employee #183, the area human resource manager, stated that they did not have a WV Cares Notification of Eligible Fitness Determination letter for Employee #150. She stated that she was finger printed on 04/05/17 by MorphoTrust but that the results were never sent to WV Cares. She indicated she did not realize that they had not been sent to WV CARES until she went to pull it from the WV CARES system when it was requested by the surveyor on 08/30/17. b) Resident #322 A review of the reportable incidents beginning at 10:40 a.m. on 08/30/17 found an Immediate Fax Reporting of Allegations - Nursing Home Program completed on 07/27/17 listing Resident #322 as the alleged victim. On the form under the section titled, Brief Description of the Incident the following was hand written: (typed at written) Resident alleges (unidentified) CNA (Certified Nursing Assistant) is rude, yells, and cusses at him and he alleges this CNA told him that they were not going to change him every 2 (two) hours. Review of the five - day follow up pertaining to this allegation completed by Licensed Practical Nurse (LPN) Social Service Manager (SSM) #15 found the following: (typed as written) I spoke with the resident and he told me that the CNA was (first name of Nurse Aide (NA) #13) . I spoke with the CNA (first and last name of NA #13) who told me she recall the evening and stated in fact the resident was the one who was cussing and screaming and she stated she immediately went out and told the co worker what had happened. During an interview with LPN - SSM #15 beginning at 3:35 p.m. on 08/30/17 in regards to this allegation she stated this was not reported to the Nurse Aide Program after a Nurse Aide was identified because she spoke with Resident #322 and he had stated the NA just needed to be fine tuned and therefore she did not feel it was substantiated so she did not report it to the Nurse Aide Program. c) Resident #372 A review of the reportable incidents beginning at 10:40 a.m. on 08/30/17 found an Immediate Fax Reporting of Allegations - Nursing Home Program completed on 08/01/17 listing Resident #372 as the alleged victim. On the form under the section titled, Brief Description of the Incident the following was typed: (typed as written) The residents son alleges the following: Resident has had a decline in status and wont do anything, call light not answered timely, alleges waited 3 1/2 hours to be changed after a bowel movement and pain medication it not effective enough. Review of the five - day follow up pertaining to this allegation completed by LPN - SSM #15 found the following: (typed as written) . In regards to allegation of having a bowel movement and waiting 3 hours to be changed. he states this was Saturday into Sunday from 4:30 a.m. to 8:00 a.m During an interview with LPN-SSM #15 beginning at 3:35 p.m. on 08/30/17, when asked if once the resident gave her a specific time frame if she reported the Nurse Aide who was assigned to him during this time frame to the Nurse Aide Program as an alleged perpetrator she stated, No because the allegation was not substantiated therefore I did not report it to the Nurse Aide Program. She further stated, Maybe I should have done that. d) Resident #280 A review of the reportable incidents beginning at 10:40 a.m. on 08/30/17 found an Immediate Fax Reporting of Allegations - Nursing Home Program completed on 07/26/17 listing Resident #280 as the alleged victim. On the form under the section titled, Brief Description of the Incident the following was hand written: (typed as written) Resident alleged CNA took her to the shower room and during the time in the shower alleges CNA left shower and told her she had to get another resident off the bedpan - states CNA was gone less than five minutes and no issues occurred . Review of the five - day follow up pertaining to this allegation completed by LPN - SSM #15 found the following: (typed as written) After interviewing the resident, it was found the date she is alleging was 07/17/17. It was also found out that the CNA was (First and Last Name of NA #145). I spoke with (First Name of NA #145) regarding this allegation and she reports she does remember this day and she took the resident to the shower and it was very hot in the shower room. She stated that (First name of Resident #280) was safely in her chair and she told the resident she was going to open the first door to the shower room to catch her breath and she would be able to hear her (stating it was just a few feet away) During an interview with LPN-SSM #15 beginning at 3:35 p.m. on 08/30/17, when asked if once the Nurse Aide was identified if this allegation was then reported to the Nurse Aide Program she stated, No it was not, because it was unsubstantiated so I did not think to report it. e) Resident #84 A review of the complaints and concerns beginning at 12:00 p.m. on 08/30/17 found a concern form dated 06/19/17 which identified Resident #84 as the Resident involved. Under the section titled, Description of Concern the following was hand written: (typed as written) Daughter states he did not get shower, toothbrush or water pitcher from Saturday until Wednesday. Feels like they left him up too long in his wheelchair on Wednesday. Review of the reportable incidents for the month (MONTH) (YEAR) found no reportable incident related to concern voiced by Resident #84's daughter. During an interview with LPN-SSM #15 beginning at 3:35 p.m. on 08/30/17, when asked if this allegation was reported as an allegation of neglect she stated, No because I pulled the ADL (Activities of Daily Living) flow sheet report immediately and the daughter was fine with that. f) Resident #110 A review of the complaints and concerns beginning at 12:00 p.m. on 08/30/17 found a concern form dated 07/15/17 which identified Resident #110 as the resident involved. Under the section titled, Description of Concern the following was hand written: (typed as written) Resident stated she had been asking since lunch time to be cleaned up. Went into room at 3:45 p.m. to change dressing and resident voiced concern about not being cleaned. CNA went into room to clean up resident at this time. Resident states this is not the first time. Resident room partner stated yellow ring around the residents sheet. Review of the reportable incidents for the month of (MONTH) (YEAR) found no reportable incident related to concern voiced by Resident #110. An interview with the Nursing Home Administrator (NHA) at 4:21 p.m. on 08/30/17, confirmed he was the person who handled this concern for Resident #110. When asked if this concern had been reported as an allegation of neglect he stated, No because after doing further interviews he did not feel like it was a reportable incident. g) Resident #233 A review of the complaints and concerns beginning at 12:00 p.m. on 08/30/17 found a concern form dated 07/17/17 which identified Resident #233 as the resident involved. Under the section titled, Description of Concern the following was hand written: (typed as written) Resident reports that the weekend was terrible and her got into an argument with RCS - (First name of RCS) on 4 occasions. Reports a very bad attitude - that she put him down on Saturday as refusing a bath and he did not refuse. She would not make his bed how he asked her too. She fuss with me every time she to come into my room. My roommate laid in a dirt brief from breakfast to noon yesterday. They would come in and turn light off and would not change him. Finally around noon he got changed. Last night (Sunday after Midnight) I put my call light on and it took 40 minutes to get someone in here. Review of the reportable incidents for the month of (MONTH) (YEAR) found no reportable incident related to this concern voiced by Resident #233. An interview with the NHA at 4:11 p.m. on 08/30/17 confirmed this concern was not reported as an allegation of abuse and/or neglect. He indicated after he finished up his investigation he did not feel it was substantiated therefore he did not report it. h) Resident #290 A review of the complaints and concerns beginning at 12:00 p.m. on 08/30/17 found a concern form dated 07/16/17 which identified Resident #290 as the resident involved. Under the section titled, Description of Concern the following was hand written: (typed as written) Husband states nurse forced her to take medicine, among other issues. Wants to talk to administrator . Review of the reportable incidents for the month of (MONTH) (YEAR) found no reportable incident related to this concern voiced by Resident #290. An interview with the NHA at 4:19 p.m. on 08/30/17, confirmed this allegation of abuse was not reported. He stated that after he talked to Resident #290's husband it was clear the nurse was just adamant that the resident take her medicine and she did not force her to take it. He indicated that is why he did not report this allegation of abuse. i) Resident #367 On 08/29/17 at 11:14 a.m., during a Stage 1 interview of the QIS survey, Resident #96 said a female resident across the hall from him had yelled for 30 minutes needing a bed pan. Resident #96 did not know if the other resident's call light was on. Resident #96 also did not know if this resident ever received assistance. During an interview with Administrator #107, on 09/07/17 at 10:38 am., he said he did have knowledge of this issue and had spoken with Resident #96 and had identified Resident #367 as the resident who needed assistance. During the interview, on 09/07/17 at 10:38 a.m., Administrator #107 provided hand written notes dated 08/21/17. The notes reflect Administrator #107's conversation with Resident #96 and Resident #367. Resident #367 was identified as having a [DIAGNOSES REDACTED].#107's conversation with Resident #367 the resident denied having any issues with needing a bedpan the night before. The administrator noted the resident had a catheter, was on a toileting plan and was care planned for yelling out and turning call light on continuously. Administrator #107 said he had not interviewed any staff regarding this issue nor had he identified this as an allegation of neglect. He also confirmed he had not reported this issue to the appropriate outside State agencies. He said he did not report this issue because after speaking with the resident and obtaining information from other sources he concluded the resident had not been neglected. j) Policy Review A review of the facility's Abuse and Neglect Prohibition Policy with revision date of (MONTH) (YEAR), on 08/30/17 at 9:00 a.m., found the following under the section titled Reporting and Response: 1. The facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of property to the administrator, State Survey Agency, and law enforcement officials and Adult Protective Services (where state law provides for jurisdiction in long term care facilities) in accordance with state law through established procedures. Timeline for reporting is as follows: a. If the events that caused the allegation involve abuse or result in serious bodily injury, a report is made no later than 2 hours after the management staff becomes aware of allegation. b. If the events that cause the allegation do not involve abuse and do not result in serious bodily injury a report is made not later than 24 hours after the management team become aware of the allegation 3. The facility will report any occurrences of abuse by licensed or certified staff and any knowledge it has of actions by a court of law against an employee , which would indicate unfitness for employment to the applicable state board in accordance with the state law.",2020-09-01
113,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,226,E,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to develop an abuse policy that included all required components. The policy did not address training related to dementia management and resident abuse prevention. The policy also included time frames for reporting abuse that were established from the time the management staff became aware of the allegation and not the actual time the allegation was made. In addition, the facility did not implement its policy as it pertained to the reporting of all allegations of abuse and neglect. The facility failed to report all allegations of abuse and/or neglect to the appropriate state agencies for four (4) of fifty-five (55) complaints/concerns completed by the facility for the month of (MONTH) (YEAR). The allegations not reported involved Resident # 84, #110, #233, and #290. Also there was one allegation of neglect made in regards to Resident #367 which was not written on a concern form and it was also not reported to the appropriate state agencies. Also, the facility failed to report three (3) of 35 reportable's to the appropriate state agency. The facility reported these allegations to the nursing home program even though a nurse aide was identified during the investigation as the alleged perpetrator therefore the allegations should have been reported to the Nurse Aide Program. These reportable instances involved Resident #322, #372, and #280. The failure of the facility to develop a policy that contains all required components and the failure of the facility to implement their current policy has the potential to effect all residents currently residing in the facility. Resident Identifiers: #84, #110, #233, #290, #322, #372, #367, and #280. Facility Census: 180. Findings Include: a) Policy Development 1. Dementia Management and Resident Abuse Prevention. A review of the facility's Abuse and Neglect Prohibition policy with a revision date of (MONTH) (YEAR), at 9:00 a.m. on 08/30/17 found the following pertaining to the training of employees: 1. The facility will train each employee on this policy during orientation, annually, and more often as determined by the facility. 2. The facility will provide training regarding related policies and procedures. 3. The facility will provide education for those individuals involved with the resident (i.e. family responsible party or legal representative, visitors.) Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities revision 168, with a revision date of 03/08/17 found the following, F226 ** (Rev. 168, Issued: 03-08-17, Effective: 03-08-17, Implementation: 03-08-17) 483.12(b) The facility must develop and implement written policies and procedures that . (3) Include training as required at paragraph 483.95 . 483.95(c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in 483.12, facilities must also provide training to their staff that at a minimum educates staff on- 483.95(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at 483.12. 483.95(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property 483.95(c)(3) Dementia management and resident abuse prevention. 483.95(c)(1) and 483.95(c)(2) are covered in the facility's policy which the facility indicates they will train the staff, however 483.95(c)(3) dementia management and resident abuse prevention is not contained in the policy. These findings were discussed with the Nursing Home Administrator (NHA) at 9:22 a.m. on 08/31/17. He stated that he would have to make sure this was the most recent policy they had in place. At 9:32 a.m. on 08/31/17 the NHA stated that this was the most recent policy they had. He confirmed dementia management and resident abuse prevention was not contained in this policy as required. 2. Reporting and Response A review of the facility's Abuse and Neglect Prohibition Policy with revision date of (MONTH) (YEAR), on 08/30/17 at 9:00 a.m., found the following under the section titled Reporting and Response: 1. The facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of property to the administrator, State Survey Agency, and law enforcement officials and Adult Protective Services (where state law provides for jurisdiction in long term care facilities) in accordance with state law through established procedures. Timeline for reporting is as follows: a. If the events that caused the allegation involve abuse or result in serious bodily injury, a report is made no later than 2 hours after the management staff becomes aware of allegation. b. If the events that cause the allegation do not involve abuse and do not result in serious bodily injury a report is made not later than 24 hours after the management team becomes aware of the allegation 3. The facility will report any occurrences of abuse by licensed or certified staff and any knowledge it has of actions by a court of law against an employee , which would indicate unfitness for employment to the applicable state board in accordance with the state law. Review of the State Operations Manual (SOM) Appendix PP - Guidance to Surveyors for Long Term Care Facilities revision 168, with a revision date of 03/08/17 found the following in regards to F225 and reporting of allegations: 483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. The SOM specifies that reporting is to be done within 2 hours or 24 hours depending on the circumstances after the allegation is made not after the management team has been made aware of the allegation. These findings were discussed with the Nursing Home Administrator (NHA) at 9:22 a.m. on 08/31/17. He stated that he would have to make sure this was the most recent policy they had in place. At 9:32 a.m. on 08/31/17 the NHA stated that this was the most recent policy they had. He confirmed their policy indicating the reporting times began after the management team was made aware of the allegation. He stated we always have a manger here and staff are to immediately report to the manager any allegations or abuse or neglect to get the process started. b) Policy Implementation in regards to reporting of alleged abuse and or neglect, A review of the facility's Abuse and Neglect Prohibition Policy with revision date of (MONTH) (YEAR), on 08/30/17 at 9:00 a.m., found the following under the section titled Reporting and Response: 1. The facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of property to the administrator, State Survey Agency, and law enforcement officials and Adult Protective Services (where state law provides for jurisdiction in long term care facilities) in accordance with state law through established procedures . Timeline for reporting is as follows: a. If the events that caused the allegation involve abuse or result in serious bodily injury, a report is made no later than 2 hours after the management staff becomes aware of allegation. b. If the events that cause the allegation do not involve abuse and do not result in serious bodily injury a report is made not later than 24 hours after the management team become aware of the allegation. 3. The facility will report any occurrences of abuse by licensed or certified staff and any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for employment to the applicable state board in accordance with the state law. The following instances were found where the facility failed to implement their policy related to reporting and response: 1) Resident #322 A review of the reportable incidents beginning at 10:40 a.m. on 08/30/17 found an Immediate Fax Reporting of Allegations - Nursing Home Program completed on 07/27/17 listing Resident #322 as the alleged victim. On the form under the section titled, Brief Description of the Incident the following was hand written: (typed at written) Resident alleges (unidentified) CNA (Certified Nursing Assistant) is rude, yells, and cusses at him and he alleges this CNA told him that they were not going to change him every 2 (two) hours. Review of the five - day follow up pertaining to this allegation completed by Licensed Practical Nurse (LPN) Social Service Manager (SSM) #15 found the following: (typed as written) I spoke with the resident and he told me that the CNA was (first name of Nurse Aide (NA) #13) . I spoke with the CNA (first and last name of NA #13) who told me she recall the evening and stated in fact the resident was the one who was cussing and screaming and she stated she immediately went out and told the co worker what had happened. During an interview with LPN - SSM #15 beginning at 3:35 p.m. on 08/30/17 in regards to this allegation she stated this was not reported to the Nurse Aide Program after a Nurse Aide was identified because she spoke with Resident #322 and he had stated the NA just needed to be fine tuned and therefore she did not feel it was substantiated so she did not report it to the Nurse Aide Program. 2) Resident #372 A review of the reportable incidents beginning at 10:40 a.m. on 08/30/17 found an Immediate Fax Reporting of Allegations - Nursing Home Program completed on 08/01/17 listing Resident #372 as the alleged victim. On the form under the section titled, Brief Description of the Incident the following was typed: (typed as written) The residents son alleges the following: Resident has had a decline in status and wont do anything, call light not answered timely, alleges waited 3 1/2 hours to be changed after a bowel movement and pain medication it not effective enough. Review of the five - day follow up pertaining to this allegation completed by LPN - SSM #15 found the following: (typed as written) . In regards to allegation of having a bowel movement and waiting 3 hours to be changed. he states this was Saturday into Sunday from 4:30 a.m. to 8:00 a.m During an interview with LPN-SSM #15 beginning at 3:35 p.m. on 08/30/17, when asked if once the resident gave her a specific time frame if she reported the Nurse Aide who was assigned to him during this time frame to the Nurse Aide Program as an alleged perpetrator she stated, No because the allegation was not substantiated therefore I did not report it to the Nurse Aide Program. She further stated, Maybe I should have done that. 3) Resident #280 A review of the reportable incidents beginning at 10:40 a.m. on 08/30/17 found an Immediate Fax Reporting of Allegations - Nursing Home Program completed on 07/26/17 listing Resident #280 as the alleged victim. On the form under the section titled, Brief Description of the Incident the following was hand written: (typed as written) Resident alleged CNA took her to the shower room and during the time in the shower alleges CNA left shower and told her she had to get another resident off the bedpan - states CNA was gone less than five minutes and no issues occurred . Review of the five - day follow up pertaining to this allegation completed by LPN - SSM #15 found the following: (typed as written) After interviewing the resident, it was found the date she is alleging was 07/17/17. It was also found out that the CNA was (First and Last Name of NA #145). I spoke with (First Name of NA #145) regarding this allegation and she reports she does remember this day and she took the resident to the shower and it was very hot in the shower room. She stated that (First name of Resident #280) was safely in her chair and she told the resident she was going to open the first door to the shower room to catch her breath and she would be able to hear her (stating it was just a few feet away) During an interview with LPN-SSM #15 beginning at 3:35 p.m. on 08/30/17, when asked if once the Nurse Aide was identified if this allegation was then reported to the Nurse Aide Program she stated, No it was not, because it was unsubstantiated so I did not think to report it. 4) Resident #84 A review of the complaints and concerns beginning at 12:00 p.m. on 08/30/17 found a concern form dated 06/19/17 which identified Resident #84 as the Resident involved. Under the section titled, Description of Concern the following was hand written: (typed as written) Daughter states he did not get shower, toothbrush or water pitcher from Saturday until Wednesday. Feels like they left him up too long in his wheelchair on Wednesday. Review of the reportable incidents for the month (MONTH) (YEAR) found no reportable incident related to concern voiced by Resident #84's daughter. During an interview with LPN-SSM #15 beginning at 3:35 p.m. on 08/30/17, when asked if this allegation was reported as an allegation of neglect she stated, No because I pulled the ADL (Activities of Daily Living) flow sheet report immediately and the daughter was fine with that. 5) Resident #110 A review of the complaints and concerns beginning at 12:00 p.m. on 08/30/17 found a concern form dated 07/15/17 which identified Resident #110 as the resident involved. Under the section titled, Description of Concern the following was hand written: (typed as written) Resident stated she had been asking since lunch time to be cleaned up. Went into room at 3:45 p.m. to change dressing and resident voiced concern about not being cleaned. CNA went into room to clean up resident at this time. Resident states this is not the first time. Resident room partner stated yellow ring around the residents sheet. Review of the reportable incidents for the month of (MONTH) (YEAR) found no reportable incident related to concern voiced by Resident #110. An interview with the Nursing Home Administrator (NHA) at 4:21 p.m. on 08/30/17, confirmed he was the person who handled this concern for Resident #110. When asked if this concern had been reported as an allegation of neglect he stated, No because after doing further interviews he did not feel like it was a reportable incident. 6) Resident #233 A review of the complaints and concerns beginning at 12:00 p.m. on 08/30/17 found a concern form dated 07/17/17 which identified Resident #233 as the resident involved. Under the section titled, Description of Concern the following was hand written: (typed as written) Resident reports that the weekend was terrible and her got into an argument with RCS - (First name of RCS) on 4 occasions. Reports a very bad attitude - that she put him down on Saturday as refusing a bath and he did not refuse. She would not make his bed how he asked her too. She fuss with me every time she to come into my room. My roommate laid in a dirt brief from breakfast to noon yesterday. They would come in and turn light off and would not change him. Finally around noon her got changed. Last night (Sunday after Midnight) I put my call light on and it took 40 minutes to get someone in here. Review of the reportable incidents for the month of (MONTH) (YEAR) found no reportable incident related to this concern voiced by Resident #233. An interview with the NHA at 4:11 p.m. on 08/30/17 confirmed this concern was not reported as an allegation of abuse and/or neglect. He indicated after he finished up his investigation he did not feel it was substantiated therefore he did not report it. 7) Resident #290 A review of the complaints and concerns beginning at 12:00 p.m. on 08/30/17 found a concern form dated 07/16/17 which identified Resident #290 as the resident involved. Under the section titled, Description of Concern the following was hand written: (typed as written) Husband states nurse forced her to take medicine, among other issues. Wants to talk to administrator . Review of the reportable incidents for the month of (MONTH) (YEAR) found no reportable incident related to this concern voiced by Resident #290. An interview with the NHA at 4:19 p.m. on 08/30/17, confirmed this allegation of abuse was not reported. He stated that after he talked to Resident #290's husband it was clear the nurse was just adamant that the resident take her medicine and she did not force her to take it. He indicated that is why he did not report this allegation of abuse. j) Resident #367 On 08/29/17 at 11:14 a.m., during a Stage 1 interview of the QIS survey, Resident #96 said a female resident across the hall from him had yelled for 30 minutes needing a bed pan. The resident did not know if the other resident's call light was on. Resident #96 also did not know if this resident ever received assistance. During an interview with Administrator #107, on 09/07/17 at 10:38 am., he said he did have knowledge of this issue and had spoken with Resident #96 and had identified Resident #367 as the resident who needed assistance. During the interview, on 09/07/17 at 10:38 a.m., Administrator #107 provided hand written notes dated 08/21/17. The notes reflect Administrator #107's conversation with Resident #96 and Resident #367. Resident #367 was identified as having a [DIAGNOSES REDACTED].#107's conversation with Resident #367 the resident denied having any issues with needing a bedpan the night before. The administrator noted the resident had a catheter, was on a toileting plan and was care planned for yelling out and turning call light on continuously. Administrator #107 said he had not interviewed any staff regarding this issue nor had he identified this as an allegation of neglect. He also confirmed he had not reported this issue to the appropriate outside State agencies. He said he did not report this issue because after speaking with the resident and obtaining information from other sources he concluded the resident had not been neglected",2020-09-01
114,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,241,E,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, record review, observation and staff interview, the facility failed to ensure residents were treated with dignity and respect. Three (3) residents, residing in separate rooms, did not receive their meals at the same time as their roommates. These random observations were made during the meal service. In addition one (1) of three (3) residents reviewed for the care area of dignity was sent to a physicians' appointment dressed only in a brief and was not wearing his dentures. Resident identifiers: #121, #69, #19, and #73. Facility census: 180. Findings include: a) Resident #121 Observation of the noon meal at 12:34 a.m. on 08/28/17 found the resident's roommate had finished eating her noon meal. Resident #121 did not have her tray. Employee #87, a Registered Nurse (RN) unit manager said Resident #121 requires assistance with eating so she does not have her tray. The tray comes out on another cart. The staff have to pass all trays to residents who can feed themselves, then they return to provide assistance to the residents who can't feed themselves. Resident #121's tray is on the second cart. At 4:00 p.m. on 08/28/17, the Registered Nurse (RN), District Director of Clinical Services, stated, We have always served the residents who can feed themselves first. We are fixing the trays right now so roommates will have their trays at the same time. b) Resident #69 Observation of the morning meal on 08/29/17, at 8:29 a.m. found the resident's roommate had finished eating his meal. Resident #69 did not have a tray. The roommate, Resident #286 stated his roommate does not have a tray yet because someone has to feed him. He gets his tray later. c) Resident #19 Observation of the noon meal on the 400 hallway found Resident #19's roommate had finished eating her breakfast at 8:49 a.m. on 08/29/17. Resident #19 did not have her meal. Nursing assistant (NA) #58 said Resident #19's tray comes out on the second cart. She stated residents who can feed themselves get their trays first. The roommate can feed herself, Resident #19 requires assistance. We pass trays to all the residents who feed themselves on the first cart then the second cart contains the trays of all the residents who require assistance with eating. At 11:17 a.m. on 09/05/17, the Director of Nursing (DON) said all staff have been educated to make sure roommates receive their trays at the same time. This was an issue but now it has been corrected. d) Resident 73 Resident #73 was admitted to the facility with a pressure ulcer on his heel. On Tuesday mornings he was transported by ambulance to a wound care facility for treatment of [REDACTED]. Telephone interview with Resident's family member during Stage I of the survey on 08/29/17 at 11:27 a.m. revealed Resident #73 had been transported to his weekly appointment at the wound care facility dressed only in an incontinence brief. The family member was unsure of the exact date this happened, but stated it occurred approximately three (3) weeks ago. The family member also stated Resident #73 had been transported to the wound care facility without his dentures the day of the interview, 08/29/17. Unit Manager (UM) #87 was interviewed on 09/05/17 at 8:30 a.m. UM #87 stated several weeks ago there was a miscommunication with Emergency Medical Services (EMS) and Resident #73 was transferred to his appointment at the wound care facility wrapped in a sheet and dressed only in an incontinence brief. UM stated EMS did not want to wait for the resident to be dressed, and that is why they did not inform the staff Resident #87 was not dressed appropriately for an appointment. UM #87 was unable to explain why Resident #73 was in bed dressed only in an incontinence brief when EMS arrived. However, he stated it was breakfast time and hectic. He also stated Resident #73 had recently been admitted and the facility was not aware he had an appointment at the wound care facility the morning he was transferred only in an incontinence brief. UM stated he would have made sure Resident #87 had been dressed if he had been aware the resident was not dressed. During the interview on 09/05/17 at 8:30 a.m., UM #87 also stated he was aware that Resident #73 had been transferred to the wound care facility without his dentures. UM stated he didn't feel the resident needed his dentures for a wound care clinic. However, because the resident's family member stated she preferred the resident to wear his dentures to appointments, staff now made sure this was done. On 09/05/17 at 9:35 a.m., Resident #73 was observed being transported by EMS to his appointment at the wound care facility. Morning hygiene had been performed, and resident was dressed in a shirt and pants. He was wearing dentures. During an interview on 09/05/17 at 9:35 a.m., EMS stated they had never transported Resident #73 before, and, therefore, were unable to provide information regarding the incident during which he was dressed only in an incontinence brief. However, EMS stated the facility usually had residents ready for transportation to appointments. EMS stated they would alert the nurse if a resident was not dressed, but sometimes they have to transport the resident anyway due to time constraints. The Director of Nursing was interviewed on 09/05/17 at 11:16. She provided no further information regarding the situation.",2020-09-01
115,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,246,D,0,1,QLZ111,"Based on observation, resident interview and staff interview the facility failed to ensure once (1) resident received grooming tools to ensure she could perform activities of daily living. During this random opportunity for discovery the resident was observed having long hair on her chin. Resident identifier: #35. Facility census: 180. Findings include: a) Resident #35 On 08/29/17 at 9:12 a.m. an observation of Resident #35 revealed Resident #35 had long chin hairs. Resident #35 said, I'm growing a beard, I use to get them waxed when I went to the beauty shop. They will give you a razor but you have to ask. On 08/30/17 at 9:00 a.m. Resident Care Specialist (RCS) #145 indicated she had been assigned to work with Resident #35. RCS #145 was asked to go to Resident #35's room. Once in the room Resident #35 asked RCS #145 for a razor and RCS #145 said she would get one for her. Upon leaving the room RCS #145 agreed the resident had long hair on her chin and said the resident had never asked her for a razor. On 08/31/17 at 12:55 p.m. Resident #35 said the facility had given her a razor a few months ago but she had broken it and did not want to ask for another one. She said, they should have noticed because I was starting to look like a goat.",2020-09-01
116,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,247,D,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, record review and staff interview, the facility failed to ensure notice was provided to one (1) of four (4) residents reviewed during Stage 2 of the Quality Indicator survey (QIS) who voiced concerns regarding room moves without notification. Resident identifier: #30. Facility census: 180. Findings include: a) Resident #30 At 4:17 p.m. on 08/28/17, the resident's responsible party said the resident had been moved on several occasions and notification prior to room moves was not always provided. Review of resident census found the following dates the resident was moved to other rooms in the facility: --On 12/21/16, the resident was admitted to the facility and was placed in room [ROOM NUMBER] B on the first floor. --On 03/01/17, the resident moved from first room floor 35 B to room [ROOM NUMBER] B also on the first floor. --On 04/05/17, the resident was moved from room [ROOM NUMBER]B on the first floor to third floor, room [ROOM NUMBER] B. --On 05/09/17, the resident was moved from room [ROOM NUMBER] B to fourth floor, room [ROOM NUMBER]. --On 06/02/17, the resident was moved from fourth floor, room [ROOM NUMBER] to third floor, room [ROOM NUMBER]. --On 06/16/17, the resident was moved from room [ROOM NUMBER] to first floor, room [ROOM NUMBER]. --On 06/27/17, the resident was moved to third floor, room [ROOM NUMBER]. --On 07/10/17 the resident was moved from room [ROOM NUMBER] to room [ROOM NUMBER] on the third floor. Record review found the facility provided written forms, entitled, Notification Of Room Change, for the room moves occurring on 04/05/17, 06/02/17, 06/27/17, 07/10/17. The notification was provided to the responsible party. Review of the medical record with the director of nursing (DON) at 10:08 a.m. on 09/06/17, found the facility had no documentation the responsible party/resident was notified of the room moves occurring on 03/01/17, 05/09/17, and 06/16/17. The DON confirmed the responsible party should have been notified of the room changes as the resident does not have capacity to make health care decisions.",2020-09-01
117,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,272,D,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a complete and accurate minimum data set (MDS) for one (1) of twenty-nine (29) residents whose MDS's were reviewed during Stage 2 of the Quality Indicator survey (QIS). Resident #19's MDS was incorrect in the area of diagnosis. Resident identifier: #19. Facility census: 180. Findings include: a) Resident #19 Review of the current residents Medication Administration Record [REDACTED]. On 04/20/17, the pharmacist advised the physician to please consider either documenting more appropriate justification for use of the [MEDICATION NAME] or titrate off this agent until justification is apparent or it is possible to discontinue the agent. At 2:55 p.m. on 08/30/17, the Director of Nursing (DON) provided a physician's progress visit note, completed by Employee #178, the Advanced Practice Registered Nurse. The visit was signed by E #178 on 05/02/17. Documentation noted the resident had a [DIAGNOSES REDACTED]. At 12:12 p.m. on 09/05/17, two (2) Advanced Nurse Practioners, #177 and #178 who visit the resident at the facility, said the resident has always had mental illness. Employees #117 and #178 provided a copy of a visit by a third Advanced Practice Registered Nurse indicating the resident had mental illness on 11/04/16. This visit noted the resident had a [DIAGNOSES REDACTED].#178 said she had spoken to the family members of the resident and she believed the son also told her about the mental illness. E#178 said the third Advanced Nurse Practioner specialized in psychiatric illness. [NAME] #178 did not explain why the [DIAGNOSES REDACTED]. One annual minimum data set (MDS) with an assessment reference date (ARD) of 03/12/17 was completed after the [DIAGNOSES REDACTED]. Section I, of the MDS provides boxes to check for a [DIAGNOSES REDACTED]. and [MEDICAL CONDITION]. The MDS did not reflect the resident had a [DIAGNOSES REDACTED]. The Registered Nurse (RN), Resident Care Manager, RN #3, said she coded the MDS's but did not know the medication was being given for a mental illness during her interview at 1:18 p.m. on 09/05/17. If that's what they are giving it for, then they should say so.",2020-09-01
118,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,278,E,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure four (4) quarterly minimum data sets (MDS's) were accurately completed for one (1) of twenty-nine (29) residents whose MDS's were reviewed during Stage 2 of the Quality Indicator survey (QIS). Resident #19's quarterly MDS's were incorrect in the area of diagnosis. Resident identifier: #19. Facility census: 180. Findings include: a) Resident #19 Review of the current residents Medication Administration Record [REDACTED]. On 04/20/17, the pharmacist advised the physician to please consider either documenting more appropriate justification for use of the [MEDICATION NAME] or titrate off this agent until justification is apparent or it is possible to discontinue the agent. At 2:55 p.m. on 08/30/17, the Director of Nursing (DON) provided a physician's progress visit note, completed by Employee #178, the Advanced Practice Registered Nurse. The visit was signed by E #178 on 05/02/17. Documentation noted the resident had a [DIAGNOSES REDACTED]. At 12:12 p.m. on 09/05/17, two (2) Advanced Nurse Practioners, #177 and #178 who visit the resident at the facility, said the resident has always had mental illness. Employees #117 and #178 provided a copy of a visit by a third Advanced Practice Registered Nurse indicating the resident had mental illness on 11/04/16. This visit noted the resident had a [DIAGNOSES REDACTED].#178 said she had spoken to the family members of the resident and she believed the son also told her about the mental illness. E#178 said the third Advanced Nurse Practioner specialized in psychiatric illness. [NAME] #178 did not explain why the [DIAGNOSES REDACTED]. Four quarterly MDS's have been completed since the [DIAGNOSES REDACTED]. 02/16/16, 06/05/17, 07/28/17, and 08/18/17. Section I, of the MDS provides boxes to check for a [DIAGNOSES REDACTED]. and [MEDICAL CONDITION]. None of the four (4) quarterly MDS's coded the resident as having a [DIAGNOSES REDACTED]. The Registered Nurse (RN), Resident Care Manager, RN #3, said she coded the MDS's but did not know the medication was being given for a mental illness during her interview at 1:18 p.m. on 09/05/17. If that's what they are giving it for, then they should say so.",2020-09-01
119,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,279,D,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interview, the facility failed to identify and develop a comprehensive care plan for significant weight loss for one (1) of twenty-nine (29) residents reviewed during Stage 2 of the Quality Indicatior Survey. Resident Identifier: #320. Facility Census: 180 Findings include: a) Resident #320 Resident #320 lost 10.8% (percent) of his body weight, from 04/22/17 to 05/05/17, which represented a severe weight loss. Additionally, Resident #320 lost 13.1% of his body weight from 04/22/17 to 06/04/17, which again represented a severe weight loss. There was no evidence the facility identified these weight losses nor assessed causes and/or provided interventions to prevent additional weight loss. A record review on 09/05/17 at 12:08 p.m., revealed the Nursing Initial Plan of Care completed on 04/22/17, Section E. Nutrition, 1. Focus, 2. Goal, 3. Interventions, and 4. Responsible Disciplines had no responses. It was signed by Employee #87. The Nursing Care Plan completed on 06/06/17, which was the current care plan at the time of this review, stated, Focus: (First name of resident #320) has nutritional problem or potential nutritional problem (skin breakdown) r/t Obesity (weight 277, BMI/IBW 34.6/196-206). Date Initiated: 04/28/2017. Revision on: 04/28/2017. Goal: (First name of resident #320) will have gradual weight loss (1-2 lbs per month) through review date. Date Initiated: 04/28/2017. Revision on: 05/03/2017. Target Date: 08/02/2017. (Resident #320's last name) will maintain adequate nutritional status as evidenced by maintaining weight within (10)% of (196), no s/sx of malnutrition, and consuming at least (50)% of at least (2) meals daily through review date. Date Initiated: 04/28/2017. Revision on: 05/03/2017. Target Date: 08/02/2017. (First name of resident #320) will not develop complications related to obesity, includng skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, impaired moblity through review date. Date Initiated: 04/28/2017. Revision on: 05/03/2017. Target Date: 08/02/2017. Interventions: (included) Develop an activity program that includes exercise, mobility. Offer activities of choice to help divert attention from food. Date Initiated: 04/28/2017. Observe/record/ report to MD PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss. Date Initiated: 04/28/2017. RD to evaluate and make diet change recommendations PRN. Date Initiated: 04/28/2017. Weigh at same time of day and record each month. Date Initiated: 04/28/2017 Revision on 04/28/2017. A record review on 08/30/17 at 8:28 a.m., revealed the folllowing weights for Resident #320: -- 04/22/17: 277.0 pounds -- 05/05/17: 247.0 pounds (-10.8%, -30.0 pounds) -- 06/04/17: 240.8 pounds (-13.1%, -36.2 pounds) The resident's percentage of weight loss from 04/22/17 to 05/05/17 and from 04/22/17 to 06/06/17 were calculated using the following formula % of weight loss = (usual weight - actual weight) / (usual weight) x 100. -- From 04/22/17 to 05/05/17, the resident lost 10.8% of his body weight. -- From 04/22/17 to 06/04/17, the resident lost 13.1% of his body weight. Review of resident #320 physician's orders [REDACTED]. Dietary supervisor clarified this order as Controlled Carbohydrate Diet, No Added Salt Diet, Regular Texture, Regular Consistency. From 4/22/17 to 5/19/17, two (2) Nutrition Data Collection had been completed. The first note, description admitted d 4/22/17 at 12:00 p.m., signed and locked 4/28/17 at 2:17 p.m The most recent weight was noted in Section A: 277.0 Lbs on 4/22/17 at 1:54 p.m. The Diet/Supplement/Snack/Fortified Foods was noted in Section I, 2 Regular Diet and the Average meal intake percentage/day was noted in Section A: 1,3 50-75%. The Summary/Plan/Progress Note was noted in Section K,2, which included, Resident evaluated for initial admission nutritional status. Current diet is NAS with average intake of 75-100%, which is adequate to meet needs. Weight is 277/34.6, and indicates overweight/obesity status. Current diet order is adequate and appropriate. Will follow prn. The second Nutrition Data Collection dated 5/19/17 at 10:45 a.m., signed and locked 5/30/17 at 09:24 a.m. by Employee #182. The most recent weight was noted in Section A: 249.6 on 5/10/17 at 09:39. Section B, Weight Status, 1. Is there a change in weight? Response: a. No Change. In 3. Weight Loss =/> 5% in 30 days, 7.5% in 90 days, or 10% in 180 days?; however, there was No Response noted in this section. In 4. Please select concerning =/> 5% weight loss; however there was No Response noted in this section. In Section I, 2,Diet/Supplement/Snack/Fortified Foods: CCD/NAS/REG texture. Section I. 3 Average meal intake percentage/day: 100%. In Section K Summary/Plan/Progress Note: Pt with history of GERD/T2DM/Unsteady Gait/Pt is post home-invasion with facial trauma. No problems with eating. Glucose is running elevated. He has a history low H&H and depressed [MEDICATION NAME]. Per pt he has no problems. The Nutrition RD assessment dated [DATE] at 09:03 a.m., signed and locked 5/3/17 at 09:06. Section A: Nutrient Estimated Needs, 1. Calories: 20-25/kg ABW of 98kg=1965-2450. 2. Protein: 1-1.1g/kg ABW=98-108. 3. Fluid: 1mL/kcal= 1965-2450. Section B : Nutrition Diagnosis, 1d. Predicted excessive energy intake NI-1.5. Section C: Problem/Etiology/Signs/Symptoms Statement, 3. Nutrition Goals: Maintain/improve nutritional status. Slow, gradual wt. loss of 3-5 # per month. Avg intake >50%. The Nutrition Status Review dated 7/22/15 at 12:00 p.m, signed and locked 7/29/17 at 5:40 p.m Section B: Weight Status, 3 Weight Loss =/> 5% in 30 days, 7.55 in 90 days, or 10% in 180 days?: No Response. In 4. Please select concerning =/>5% weight loss: No Response. The Nursing Monthly Summary for Resident #320, dated 6/23/17 at 2:00 p.m., signed and locked 6/23/17 at 3:09 p.m., noted Eating 4h: Usual Appetite: b. Fair. Interview was conducted with Resident #320 on 9/5/17 from 1:45 PM-2:30 p.m. The resident explained the events that led up to his admission in April, as well as the therapy received initially. He stated that his appetite when first admitted to the facility was I don't remember much when I first came here. I guess I ate pretty good. I don't really know. I don't have any problem eating now, though. When asked if he was aware he had lost weight after his admission, he replied, No, I really don't. They keep record of it I guess, so I guess they took care of it. Resident #320 said, I don't have any problems eating now. When asked if the staff ever offer him something else to eat, if he doesn't eat and/or like what has been served, he replied, No, I guess they would if I'd ask. Interview was conducted with Employee #40 on 9/7/17 at 9:17 a.m. regarding Resident #320's noted weight loss for April, (MONTH) and (MONTH) (YEAR). She reviewed the Weight Summary report and noted the weight loss for this time period and stated I'll have to talk with (First name of Employee #180) and check if there were interventions for his weight loss. No other information was provided during the survey.",2020-09-01
120,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,280,E,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, family interview and resident interview the facility failed to ensure four (4) of twenty-nine (29) residents whose care plans were reviewed had care plans that were revised as the resident's needs changed. The facility failed to revise Resident #59's care plan in the area of incontinence, Resident #84's care plan was not revised in the area of nutritional status, Resident #284's care plan was not revised in the area of accidents after a resident experienced three (3) falls, and Resident #286's care plan in the area of discharge planning. Additionally, Resident 19's responsible party was not given enough notice to attend care plan meetings. Resident identifiers: #59, #84, #284, #286 and #19 Facility census: 180. Findings include: a) Resident #59 The Minimum Data Set (MDS) review for Resident #59 indicated this resident was assessed as occasionally incontinent on the admission MDS. On the quarterly MDS, completed on 06/02/17, this resident was assessed as frequently incontinent. The care plan review revealed a focus area of occasional incontinence. This focus area was initiated on 03/27/17. The goal for the resident to be continent at all times was revised on 04/18/17 with a target date of 07/17/17. During an interview on 09/07/17 at 10:21 a.m. with Registered Nurse/MDS #46 she confirmed the resident's care plan was not revised to show the resident's decline from occasional to frequent incontinence. b) Resident #84 The medical record review for Resident #84 revealed a weight loss between the dates of 07/11/17 and 08/15/17. The resident weighed 207 pounds (lbs) on 07/11/17 and 180 lbs on 08/15/17. While in the hospital on [DATE] a weight was recorded as 187 lbs. The care plan dated 08/05/17 stated Resident #84 was at nutritional risk related to history of therapeutic diet, [MEDICAL CONDITIONS], hypertension, wound, [MEDICAL CONDITION] and abnormal labs. On 07/11/17 the physician ordered [MEDICATION NAME] 20 milligram (mg) every day for 3 days due to [MEDICAL CONDITION]. On 07/20/17 the physician ordered [MEDICATION NAME] 20 mg once a day for three days due to [MEDICAL CONDITION]. On 08/02/17 the physician ordered [MEDICATION NAME] 40 mg for five (5) days once a day for [MEDICAL CONDITION]. The nurse practitioner had indicated the resident had [MEDICAL CONDITION] on 06/29/17, 07/07/27, 07/24/17, 08/01/17 and on 08/04/17 the [MEDICAL CONDITION] was noted as stable. On 09/05/2017 at 2:56 p.m. during an interview with Registered Dietician (RD) #181 regarding the resident's nutritional care plan, RD #181 agreed the plan for nutrition did not take into account that the residents' weight fluctuations could be related to [MEDICAL CONDITION]. In a progress note from the dietician dated 09/06/17, the dietician indicated the resident's weight loss could be multi-factorial due to increased [MEDICATION NAME] due to [MEDICAL CONDITION] and [MEDICAL CONDITION]. c) Resident #284 Resident #284 was originally admitted to the facility on [DATE], and was discharged on [DATE]. Care planning related to a risk for falls was initiated on 03/29/17. Resident #284 was readmitted to the facility on [DATE]. The care plan goal revised on 06/20/17 was (Resident #284) will be free of falls through the review date. The care plan focus revised on 06/22/17 was (Resident #284) is at risk for falls related to impaired cognition, muscle weakness, impaired balance, wounds. On 07/30/17 at 7:45 p.m., Resident #284 was found lying face first on the floor beside his bed. He suffered an abrasion to his left forearm and a skin tear to his right hand. On 07/31/17, bilateral floor mats at all times were ordered. An updated care plan intervention for bilateral floor mats was also initiated on 07/31/17. On 08/01/17 at 5:00 a.m., Resident #284 was again found lying on the floor next his bed. A small circular skin tear was noted to his left great toe. On 09/0517 at 5:34 a.m., Resident #284 was again found lying on the floor next to his bed. No injury was noted. Resident #284's care plan focus and goal were not updated after he experienced three (3) falls. During an interview on 09/06/2017 at 4:06 p.m., the Director of Nursing (DON) had no additional information about the care plan not being updated to reflect that Resident #284 had experienced falls. On 09/06/17, after the DoN had been interviewed, the care plan focus related to falls was updated to (Resident #284) has experienced a fall and is expected to experience further falls related to impaired mobility, impaired cognition, poor safety awareness and history of falls. The goal was updated to (Resident #284) will be free of injury as a result of fall through next review period. d) Resident #286 Review of the resident's admission minimum data set (MDS) with an assessment reference date (ARD) of 4/26/17 noted the resident participated in his care plan and expected to be discharged to the community. According to the MDS active discharge planning was occurring for the resident to return to the community. Review of the current care plan found the following problem: (Name of Resident) wishes to return home to his trailer at discharge however his HCS (Health Care Surrogate) would like possible long term placement. The goal associated with the problem: (Name of Resident) will be able to verbalize required assistance post-discharge and the services required to meet needs before discharge. Interventions included: Establish a pre-discharge plan with the resident/family/caregiver and evaluate progress and revisit plan as needed. Evaluate the resident's motivation to return to the community. At 2:26 p.m. on 09/05/17, Employee #77 (social worker) said the resident had to re-gain capacity before going home. She verified the care plan did not entail the steps the resident needed to take to complete his discharge to home. She could provide no evidence the care plan was updated with a specific pre-discharge plan. e) Resident #19 A family interview with the resident's responsible party, by telephone, at 9:43 a.m. on 08/29/17, found the facility provided, short notice, for care plan attendance. The responsible party said she needed at least a 2 week notice or more to be able to schedule time away from work to attend the care plans. Review of the paper medical record at 9:05 a.m. on 08/30/17, found the following invitations to care plan meetings for Resident #19: March 28, (YEAR) at 11:15 a.m. April 18, (YEAR) at 10:00 a.m. June 15, (YEAR) at 11:15 a.m. August 15, (YEAR) at 1:00 p.m. Each invitation letter was a form letter, containing the following information, A care plan conference will be held for (Name of Resident) (date and time). This time has been set aside to review the plan of care being provided by our facility. Please inform the Resident Care Management Department at least one day prior to the above scheduled time if you plan to attend. If you are unable to attend and would like a phone conference, please call and schedule. Thank you, The resident care management department Each letter contained the same information and did not indicate to whom the letter was mailed, or the date the invitation was generated. Upon interview, on 8/30/17 at 9:05 a.m., Employee #133, the minimum data set (MDS) coordinator, said she was in charge of mailing the care plan invitations . She could not provide documentation to verify when the care plan letter was actually mailed. She stated, If she would have called I could re-schedule. The letter says if you are unable to attend and would like a phone conference to please call. The Responsible party said she wanted to attend the care plan in person but did not have time to schedule time away from work. At 9:55 a.m. on 08/30/17, [NAME] #133 confirmed she had no way to verify when the care plan letter was actually mailed to the responsible party. c) Resident #284 Resident #284 was originally admitted to the facility on [DATE], and was discharged on [DATE]. Care planning related to a risk for falls was initiated on 03/29/17. Resident #284 was readmitted to the facility on [DATE]. The care plan goal revised on 06/20/17 was (Resident #284) will be free of falls through the review date. The care plan focus revised on 06/22/17 was (Resident #284) is at risk for falls related to impaired cognition, muscle weakness, impaired balance, wounds. On 07/30/17 at 7:45 p.m., Resident #284 was found lying face first on the floor beside his bed. He suffered an abrasion to his left forearm and a skin tear to his right hand. On 07/31/17, bilateral floor mats at all times were ordered. An updated care plan intervention for bilateral floor mats was also initiated on 07/31/17. On 08/01/17 at 5:00 a.m., Resident #284 was again found lying on the floor next his bed. A small circular skin tear was noted to his left great toe. On 09/0517 at 5:34 a.m., Resident #284 was again found lying on the floor next to his bed. No injury was noted. Resident #284's care plan focus and goal were not updated after he experienced three (3) falls. During an interview on 09/06/2017 at 4:06 p.m., the Director of Nursing (DoN) had no additional information about the care plan not being updated to reflect that Resident #284 had experienced falls. On 09/06/17, after the DoN had been interviewed, the care plan focus related to falls was updated to (Resident #284) has experienced a fall and is expected to experience further falls related to impaired mobility, impaired cognition, poor safety awareness and history of falls. The goal was updated to (Resident #284) will be free of injury as a result of fall through next review period.",2020-09-01
123,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,311,D,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide restorative therapy as ordered by the physician for one (1) of three (3) resident's reviewed for the care area of activities of daily living (ADL's) during Stage 2 of the Quality Indicator Survey. Resident identifier: #19. Facility census: 180. Findings include: a) Resident #19 On 08/22/17, the physical therapist referred the resident to the facility's restorative program. On 08/24/17, the resident began the following restorative program: The goal for restorative therapy was: Maintain strength and functional mobility level Activities to be performed for restorative: 1. Stretching to Bilateral hamstrings and bilateral gastrocnemius muscles 30-45 second hold. (MONTH) do in seated or supine position 2. Therapeutic exercises for bilateral lower extremities ankle pumps, heel slides straight leg raises, hip abduction/adduction and hip flexions long arc quads, 2 sets of 10 reps; may do in seated or supine. 3. Wheel chair mobility 50-100 feet Bilateral upper extremities and bilateral lower extremities for propulsion, min Assistance to SBA (stand by assistance); instruct patient on safe turning of wheel chair, safe negotiation of obstacles and correct upper extremity and lower extremity placement. At 2:19 p.m. on 08/30/17, the unit manager, Registered Nurse (RN) #116 said the restorative aides keep paper documentation of restorative services provided to residents. RN #116 said the resident had not received any therapy and she did not know why. RN #116 called Restorative Aide (RA) #33 to review the restorative therapy services. RA #33 said the resident had not had any therapy because a second aide who normally works this floor had not been working due to an injury. RA #33 said she had not been on this floor since last Thursday because she had been pulled to the floor to work as a nursing assistant. At 12:50 p.m. on 09/05/17, RN #116 was asked if the second restorative aide had returned to work. She said the RA was in the dining room today. An interview with the second RA #42 at 1:05 p.m. on 09/05/17, found he was in the dining room assisting with lunch. RA #42 said he was on light duty so he would not be able to work with Resident #19. At 1:10 p.m. RA #33 said she worked the floor yesterday so she did not get to see the resident. She stated, I last saw her on 08/31/17 and she refused her therapy. The resident was seen only one (1) time between 08/24/17 and 08/31/17. The resident had not received restorative therapy during the month of September, according to RA #33. The DON confirmed, Resident #19 was not receiving her restorative therapy as ordered on [DATE] at 4:17 p.m. after review of the Rehabilitation/Restorative Service Delivery Record. At 4:17 p.m. on 09/05/17, the administrator confirmed RA #42 was injured on the job, sometime last week.",2020-09-01
125,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,315,D,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #141 and Resident #320 received the services and assistance necessary to maintain their bladder continence status. Resident #141 and Resident #320 both suffered a decline in bladder continence status since their admission to the facility. The facility failed to consistently provide services to these residents to help them to maintain their bladder continence status. This practice affected two (2) of four (4) residents reviewed for the care area of urinary incontinence during Stage Two (2) of the Quality Indicator Survey (QIS). Resident Identifiers: #141 and #320. Facility Census: 180. Findings Include: a) Resident #141 During a Stage 1 interview with Resident #141 at 11:12 a.m. on 08/29/17, when asked if she received enough fluids between meals Resident #141 replied, they bring me plenty to drink but I watch what I drink because I wet on myself now and I never used to do that and I don't like it so I try not to drink to much. A review of Resident #141's medical record beginning at 8:02 a.m. on 09/07/17, found Resident #141 was admitted to the facility on [DATE] at which time she had an indwelling urinary catheter. Resident #141 continued to have a catheter until 01/27/17 at which time it was removed. A review of the nurse aides documentation pertaining to urinary continence was completed beginning with (MONTH) (YEAR) through 09/07/17. This review found the following ( the review was not started until (MONTH) due to the use of the catheter until 01/27/17): In (MONTH) (YEAR) Resident #141 was incontinent of her bladder 16.25 percent (%) of the time. In (MONTH) (YEAR) Resident #141 was incontinent of her bladder 16.48 % of the time. In (MONTH) (YEAR) Resident #141 was incontinent of her bladder 5.19 % of the time. In (MONTH) (YEAR) Resident #141 was incontinent of her bladder 79.57 % of the time. In (MONTH) (YEAR) Resident #141 was incontinent of her bladder 83.70 % of the time. In (MONTH) (YEAR) Resident #141 was incontinent of her bladder 73.91 % of the time. In (MONTH) (YEAR) Resident #141 was incontinent of her bladder 78.49 % of the time. In (MONTH) (YEAR) Resident #141 was incontinent of her bladder 78.95 % of the time. Further review of the record found a physician order [REDACTED]. This order was added after the resident had a fall as an intervention to prevent further falls. This toileting plan was not initiated due to Resident #141's decline in continence status. Review of Resident #141's Minimum Data Sets (MDS) found the following: An admission MDS with an Assessment Reference Date (ARD) of 12/13/17 found the resident had an Indwelling Catheter and was occasionally incontinent of urine and was not in a toileting program. A quarterly MDS with an ARD of 03/13/17 found the resident was occasionally incontinent or urine and was not currently in a toileting program. A quarterly MDS with an ARD of 06/02/17 found the resident was frequently incontinent of urine and was not currently in a toileting program. (Please note this MDS was completed after the toileting plan was ordered on [DATE].) Further review of the record found Resident #141 had the following bowel and bladder evaluations completed. Each bowel and bladder evaluation contained these directions for completion If resident is continent of both bowel and bladder evaluation complete. If resident is Incontinent of either bowel and/or bladder continue with the evaluation: -- Evaluation Dated 12/06/17 indicated Resident #141 was incontinent of urine. (Please note at the time this evaluation was completed Resident #141 had an indwelling catheter and her continent status could not be determined as incontinent due to the catheter.) -- Evaluation Dated 03/06/17 indicated Resident #141 was continent of urine. The remainder of the evaluation was not completed because she was marked as continent of bowel and bladder therefore the evaluation was complete. -- Evaluation Dated 06/06/17 indicated Resident #141 was incontinent of bladder. The remainder of this evaluation was not complete even though it should have been completed because Resident #141 was marked as incontinent of bowel and bladder. The Director of Nursing was interviewed at 8:45 a.m. on 09/07/17 she was asked to show evidence the toileting plan initiated on 05/15/17 was being implemented by the Nurse Aides. She referred to the treatment administration record (TAR). Review of the TAR for 05/2017 through 09/07/17 found the nurses initialed the toileting plan as being completed three times daily at 7:00 a.m., 3:00 p.m., and 11:00 p.m. Further review of the TARs found on the following dates and times the nurses failed to initial the toileting plan was completed: -- 05/16/17 at 3:00 p.m. -- 05/17/17 at 7:00 a.m. -- 05/19/17 at 7:00 a.m. -- 06/08/17 at 7:00 a.m. -- 06/09/17 at 7:00 a.m. -- 07/14/17 at 3:00 p.m. -- 07/19/17 at 3:00 p.m. and 11:00 p.m. -- 07/20/17 at 3:00 p.m. -- 07/25/17 at 7:00 a.m. -- 07/26/17 at 3:00 p.m. -- 07/29/17 at 7:00 a.m. -- 09/05/17 at 3:00 p.m. The DON was then asked if the nurse aides document anywhere to indicate the resident is on a toileting program. She pulled up a follow up question report, in the electronic medical record, for Resident #141. The question which the nurse aides were asked to answer on every shift was, Is the resident on a toileting or bladder retraining program? A review of the nurse aides answers were reviewed for the time period of 05/15/17 through 09/07/17 and found the nurse aides only answered yes to this question on 05/31/17 at 8:30 a.m., 06/30/17 at 2:58 p.m., 07/21/17 at 8:39 a.m., 08/08/17 at 6:38 p.m., 08/12/17 at 9:33 a.m., 08/13/17 at 9:36 a.m., 08/17/17 at 7:35 a.m., 08/21/17 at 7:58 a.m., and 08/27/17 at 4:31 p.m. On all other days three times daily the Nurse Aides answered no to this question. The DON agreed the Nurse Aides are responsible for toileting the resident on the majority of occasions. She stated, The nurses are supposed to make sure it is done. The DON was also asked why the remainder of the bowel and bladder evaluation dated 06/06/17 was not completed. She agreed the remainder of the evaluation should have been completed because the resident was marked as incontinent of her bowel and bladder. She indicated she did not know why the evaluation was not complete and stated, It should not have let them sign it as complete with it remaining blank. A final interview was completed with the DON, the District Director of Clinical Services and the Nursing Home Administrator, at 12:20 p.m. on 09/07/17. At which time they asserted the resident's fluid intake with her meals had not decreased, but they had no way of measuring the amount of fluids which the resident took in between meals which was the subject of the Stage 1 question posed to Resident #141. They also asserted that nursing will at times toilet the resident which is likely true, but they agreed the majority of the toileting program implementation was the responsibility of the Nurse Aides who were documenting that Resident #141 was not on a toileting program. No other information was provided. b.) Resident #320 Review of Resident #320's medical record at 8/30/17 at 12:25 p.m., found: MDS Findings: Section H' Bladder and Bowel 4/29/17: H0300. Urinary Continence: *2. Frequently Incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent-voiding) 5/8/17: H0300. Urinary Continence: *2. Frequently Incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent-voiding) 5/22/17: H0300. Urinary Continence: 3. Always Incontinent (no episodes of continent voiding) 6/17/17: H0300. Urinary Continence: *2. Frequently Incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent-voiding) 7/22/17: H0300. Urinary Continence: 3. Always Incontinent (no episodes of continent voiding) Review of Braden Scale for Predicting Pressure Sore Risk: 04/22/2017 at 2:18 p.m. 2. Moisture: Degree to which skin is exposed to moisture: 3. Occasionally Moist: Skin is occasionally moist, requiring an extra linen change approximately once a day. (3 pts.) 04/25/2017 at 4:24 p.m. 2. Moisture: Degree to which skin is exposed to moisture: 1. Constantly Moist: Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. (1 pt.) 05/02/2017 at 4:24 p.m. 2. Moisture: Degree to which skin is exposed to moisture: 2. Very Moist: Skin is often, but not always moist. Linen must be changed at least once a shift. (2 pts.) 05/09/2017 at 4:24 p.m. 2. Moisture: Degree to which skin is exposed to moisture: 3. Occasionally Moist: Skin is occasionally moist, reqiring an extra linen change approximately once a day. (3 pts.) 06/16/2017 at 9:43 a.m. 2. Moisture: Degree to which skin is exposed to moisture: 3. Occasionally Moist: Skin is occasionally moist, reqiring an extra linen change approximately once a day. (3 pts.) A Verbal physician's orders [REDACTED]. Confirmed by Employee #1. The above order was discontinued by telephone on 05/05/2017 at 3:08 p.m. Confirmed by Employee #81. A Telephone physician's orders [REDACTED].#81. Review of Treatment Administration Record 05/01/2017-05/31/2017 included the following: Cleanse bilateral buttocks, coccyx, and sacrum with warm soapy water, rinse, pat dry, apply [MEDICATION NAME] cream topically and prn every shift for increased risk for skin break down. -Order Date 04/25/2017 at 4:33 p.m. -D/C Date 05/05/2017 at 2:55 p.m. Cleanse bilateral buttocks, coccyx and sacrum with warm soapy water. Rinse and pat dry-apply [MEDICATION NAME] cream topically every shift. -Order Date 05/05/2017 at 2:55 p.m. -D/C Date 07/10/2017 at 8:18 a.m. Wash coccyx with warm, soapy water, rinse, pat dry, apply [MEDICATION NAME] q shift and prn every shift for prevention. -Order Date 04/22/2017 at 6:59 p.m. -D/C Date 05/05/2017 at 3:08 p.m. Cleanse bilateral buttocks, coccyx and sacrum with warm soapy water. Rinse and pat dry-apply [MEDICATION NAME] cream topically as needed for increased risk for skin breakdown. -Order Date 05/05/2017 at 2:55 p.m. -D/C Date 07/10/2017 at 8:18 a.m. Review of Treatment Administration Record 06/01/2017-06/30/2017 included the following: Cleanse bilateral buttocks, coccyx and sacrum with warm soapy water. Rinse and pat dry-apply [MEDICATION NAME] cream topically every shift. -Order Date 05/05/2017 at 2:55 p.m. -D/C Date 07/10/2017 at 8:18 a.m. Cleanse bilateral buttocks, coccyx and sacrum with warm soapy water. Rinse and pat dry-apply [MEDICATION NAME] cream topically as needed for increased risk for skin breakdown. -Order Date 05/05/2017 at 2:55 p.m. -D/C Date 07/10/2017 at 8:18 a.m. Review of Treatment Administration Record 07/01/2017-07/31/2017 included the following: Cleanse bilateral buttocks, coccyx and sacrum with warm soapy water. Rinse and pat dry-apply [MEDICATION NAME] cream topically every shift. -Order Date 05/05/2017 at 2:55 p.m. -D/C Date 07/10/2017 at 8:18 a.m. Cleanse bilateral buttocks, coccyx, scrotum, and sacrum with warm soapy water. Rinse and pat dry- apply [MEDICATION NAME] cream topically every shift. -Order Date 07/10/2017 at 8:18 p.m. Cleanse scrotum with warm soapy water, rinse, pat dry, and apply [MEDICATION NAME] every shift. -Order Date 07/01/2017 at 5:03 a.m. -D/C Date 07/10/2017 at 8:17 a.m. Cleanse bilateral buttocks, coccyx and sacrum with warm soapy water. Rinse and pat dry -apply [MEDICATION NAME] cream topically as needed for increased risk for skin breakdown. -Order Date 05/05/2017 at 2:55 p.m. -D/C Date 07/10/2017 at 8:18 a.m. Cleanse bilateral buttocks, coccyx, scrotum, and sacrum with warm soapy water. Rinse and pat dry- apply [MEDICATION NAME] cream topically as needed for increased risk for skin breakdown. -Order Date 07/10/2017 at 8:18 p.m. Review of Treatment Administration Record 08/01/2017-08/31/2017 included the following: Cleanse bilateral buttocks, coccyx, scrotum, and sacrum with warm soapy water. Rinse and pat dry- apply [MEDICATION NAME] cream topically every shift. -Order Date 07/10/2017 at 8:18 p.m. Cleanse bilateral buttocks, coccyx, scrotum, and sacrum with warm soapy water. Rinse and pat dry- apply [MEDICATION NAME] cream topically as needed for increased risk for skin breakdown. -Order Date 07/10/2017 at 8:18 p.m. Review of the Nursing Daily Skilled Charting-V 1: (4/22/17, 4/24/17, 4/25/17, 4/26/17, 4/27/17, 4/28/17, 4/29/17, 4/30/17, 5/1/17, 5/2/17, 5/3/17, 5/4/17, 5/5/17, 5/6/17, 5/7/17, 5/8/17, 5/9/17, 5/10/17, 5/11/17, 5/12/17 and 5/27/17) F. GU/BLADDER: 1 b. Bladder Continence: b. INCONTINENT (Total 21 Days) Review of the Nursing Daily Skilled Charting-V 1: (5/13/17, 5/14/17, 5/15/17, 5/16/17, 5/17/17, 5/18/17, 5/19/17, 5/21/17, 5/22/17, 5/23/17, 5/24/17, 5/25/17, 5/26/17, 5/29/17, 5/30/17 and 5/31/17) F. GU/BLADDER: 1 b. Bladder Continence: a. CONTINENT (Total 16 Days) Review of the Nursing Daily Skilled Charting-V 1: (6/9/17,6/12/17, 6/13/17, 6/26/17 and 6/27/17) F. GU/BLADDER: 1 b. Bladder Continence: b. INCONTINENT (Total 5 Days) Review of the Nursing Daily Skilled Charting-V 1: (6/1/17, 6/2/17, 6/4/17, 6/5/17, 6/6/17, 6/7/17, 6/8/17, 6/10/17, 6/11/17, 6/14/17, 6/15/17, 6/17/17, 6/18/17, 6/19/17, 6/20/17, 6/21/17, 6/22/17, 6/23/17, 6/24/17, 6/25/17, 6/28/18, 6/29/17 and 6/30/17) F. GU/BLADDER: 1 b. Bladder Continence: a. CONTINENT (Total 23 Days) Review of the Nursing Daily Skilled Charting-V 1: (7/2/17, 7/3/17, 7/4/17, 7/10/17, 7/17/17, 7/18/17, 7/19/17, 7/20/17, 7/21/17, 7/22/17, 7/23/17, 7/24/17, 7/25/17, 7/26/17, 7/27/17, 7/28/17, 7/29/17, 7/30/17, 7/31/17, 8/1/17, 8/2/17 and 8/15/17 ) F. GU/BLADDER: 1 b. Bladder Continence: b. INCONTINENT (Total 22 Days) Review of the Nursing Daily Skilled Charting-V 1: (7/1/17, 7/5/17, 7/6/17, 7/7/17, 7/8/17, 7/9/17, 7/11/17, 7/12/17, 7/13/17, 7/14/17, 7/15/17 and 7/16/17) F. GU/BLADDER: 1 b. Bladder Continence: a. CONTINENT (Total 12 Days) Review of the Nursing Monthly Summary dated 6/23/2017, Section [NAME] GU/Bladder, 1. What is resident's bladder status? a. Continent 2. Scheduled Toileting Plan 2a. Is resident on a Scheduled Toileting Plan? b. No Review of the Nursing Monthly Summary dated 7/23/2017, Section [NAME] GU/Bladder, 1. What is resident's bladder status? a. Continent 2. Scheduled Toileting Plan 2a. Is resident on a Scheduled Toileting Plan? b. No Review of the Nursing Monthly Summary dated 8/23/2017, Section [NAME] GU/Bladder, 1. What is resident's bladder status? b. Incontinent 2. Scheduled Toileting Plan 2a. Is resident on a Scheduled Toileting Plan? a. Yes Interview conducted with Resident #320 on 9/5/17 at 1:45 PM. He explained the events that led up to his admission in April, as well as the therapy he received initially. He explained that he isn't able to walk, and transfers in his wheelchair. When asked if the facility had him on a scheduled toileting program, and he replied, No. Observation found his call-light was within his reach. When asked if he turns on the call-light when he needs to go to the restroom. Resident stated, No, they come and change me twice a day, every morning and every evening. They used to change me only one time a day, and they recently increased changing me two times a day. At this time, a male Nurse Aide entered the room, carrying supplies, and stated he was there to check the resident. Approximately five (5) minutes passed, and the male Nurse Aide came out of the resident's room, pulled the door closed, and stated, I have to get some help. Approximately five (5) minutes later, the male Nurse Aide came back to Resident #320s room, along with a female Nurse Aide, who was pushing a Hoyer Lift. I asked the female staff what type of lift it was, and she replied, It's a special one that enables us to stand a resident up. Both Nurse Aides left the room in approximately 10 minutes. During an nterview with the male Nurse Aide he was asked him how often do they check and/or assist the resident, and he replied, We do it with every round. When asked how frequently do they make rounds, and he replied, It always depends on what all we've got going on. Upon re-entering Resident #320 room to resume the resident interview, he was asked if anyone had instructed him how to use his call-light, and he replied, Yes, ma'am.When asked if they had instructed him to turn on his call-light every time he needs to go to the restroom, he replied, No, I just wait until they come in to change me. When asked if the staff get a wash basin with water and soap to wash him after they remove the soiled brief. Resident smiled, and replied, No, they use those wet-ones, you know, that come in a pack. Resident added, I'm unable to stand up, so they bring a lift-thing that they use to stand me up. When asked if he had any sore or raw areas on his bottom, or between his legs and private area, and he replied, No. When asked him if the Nurse Aide or anyone applies any type of ointment, cream &/or powder on him during his care, and he replied, No. Interview conducted with Employee #40 on 9/7/17 at 9:17 a.m. regarding Resident #320's noted incontinence for April, (MONTH) and (MONTH) (YEAR), and asked if Resident #320 was on a toileting plan. She replied, I'll have to talk with (First name of Employee #180) and check if there is a toileting plan in place for this resident. No one provided this Surveyor with any additional and/or follow-up information.",2020-09-01
128,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,329,E,0,1,QLZ111,"**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 six (6) residents reviewed for the care area of unnecessary medication use were free from unnecessary medications. Resident #19 was receiving an excessive dosage of an anti-anxiety medication, identified by the pharmacist, without justification. In addition, the resident was receiving two (2) antidepressant medications without physician justification. Resident #350's insulin was not administered according to physician's orders [REDACTED]. In addition, Resident #350 received a mood stabilizer and an antidepressant without evidence of non-pharmacological interventions attempted before stating the medications. Resident identifiers: #19 and #350. Facility census: 180. Findings include: a) Resident #19 1. [MEDICATION NAME], an anti-anxiety medication On 11/25/16 the physician prescribed, [MEDICATION NAME] 1 milligram (mg.), every six (6) hours for agitation. A total of four (4) mg's in a twenty-four hour period. On 01/09/17, the prior order was discontinued and the physician ordered: [MEDICATION NAME] 1 mg., every six (6) hours for increased agitation, yelling, cursing, secondary to anxiety. The pharmacist reviewed the resident's medications on 01/13/17 and provided the following information in a written report to the physician: (Name of Resident) receives [MEDICATION NAME] 1 mg. at a total daily dose which is greater than the usual recommended maximum. Recommendations: Please consider re-evaluating continued use of [MEDICATION NAME] at this dose. If this therapy is to continue, its is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual; and b) the facility interdisciplinary team ensure ongoing monitoring for effectiveness and potential adverse consequences. The physician responded with the following comments: I have re-evaluated this therapy and do not wish to implement any changes due to the reasons below: The physician provided no reasons. The physician signed the report on 01/19/17. At 12:16 p.m. on 08/30/17, the Director of Nursing (DON) confirmed the physician did not provide rational for the use of [MEDICATION NAME] according to pharmacy instruction. The DON provided a copy of the Physician's Desk Reference (PDR) (the drug handbook used by the facility) for the use of [MEDICATION NAME].The federal Omnibus Budget Reconciliation Act (OBRA) regulates the use of anxiolytics in long-term care facility (LTCF) residents Max: 2 mg/day Po (by mouth) in residents meeting the criteria for treatment, except when documentation is provided showing that higher does are necessary to maintain or improve the resident's functional status. In addition, the facility should attempt periodic tapering or the medication or provide documentation of medical necessity in accordance with OBRA guidelines 2. Antidepressants: Mitazapine ([MEDICATION NAME]) and [MEDICATION NAME] Review of the Medication Administration Record [REDACTED] [MEDICATION NAME] 7.5 mg's at bedtime for decreased PO (by mouth) intake secondary to depression. Order date 02/24/17. [MEDICATION NAME] HCI, 50 mg's, three times a day for refusals of care related to [MEDICAL CONDITION]. ordered on [DATE]. On 07/20/17, the pharmacist reviewed the resident's medications and provided the following written report to the physician: (Name of Resident) receives two antidepressants: [MEDICATION NAME] 15 mg's and [MEDICATION NAME] HCL 50 mg TID (three times a day). Recommendation: Please re-evaluate the need for both agents. Rational for Recommendation: Use of two or more antidepressants simultaneously may increase risk of side effects; in such cases, there should be documentation of expected benefits that outweigh the associated risks and monitoring for any increase in side effects. Agents usually classified as anti-depressants may be prescribed for conditions other than depression including anxiety disorders, post-traumatic stress disorder, [MEDICAL CONDITIONS], neuropathic pain (e.g. diabetic [MEDICAL CONDITION]), migraine headaches, urinary incontinence, and others. If dual therapy is to continue, it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual; and b) The facility interdisciplinary team ensure ongoing monitoring for effectiveness and potential adverse consequences such as dizziness, nausea, diarrhea, anxiety, nervousness, [MEDICAL CONDITION], somnolence, weight gain, anorexia or increased appetite or falls. The physician responded with the following comments: I accept the recommendations above with the following modification: Decrease [MEDICATION NAME] to 7.5 mg QHS (at bedtime). The physician did not provide documentation/rational for the use of two antidepressants. At 12:16 p.m. on 08/30/17, the Director of Nursing (DON) confirmed the physician did not provide rational for the use [MEDICATION NAME] 1 mg. every 6 hours, which was greater than usual recommendation maximum. In addition, the DON confirmed the physician did not provide rational to justify the use of two (2) antidepressants. b) Resident #350 1. [MEDICATION NAME] administration Review of the resident's (MONTH) Medication Administration Record [REDACTED] [MEDICATION NAME] Flex Pen Solution Pen-injector 100 units (ML (insulin [MEDICATION NAME]). Inject 10 unit subcutaneously before meals related to Type 2 Diabetes Mellitus with [MEDICAL CONDITION], hold for Blood sugar less than 150. Order date 08/03/17. On 08/22/17 the order was changed to [MEDICATION NAME] Flex pen Solution Pen-Injector 100 unit/ML (insulin [MEDICATION NAME]). Inject 5 units subcutaneously before meals related to Type 2 Diabetes Mellitus with [MEDICAL CONDITION], hold for blood sugar less than 150. [MEDICATION NAME] was administered on the following ten (10) dates and times when the resident's blood sugar (BS) was less than 150: --08/05/17, at 5:00 p.m., BS was 148. --08/07/17, at 7:00 a.m. BS was 122 --08/09/17, at 7:00 a.m. BS was 130 --08/13/17, at 7:00 p.m. B/S 147 --08/14/17, at 7:00 a.m. B/S was 127 --08/17/17, at 7:00 a.m. B/S was 112 --08/19/17, at 11:00 a.m. B/S was 146 --08/20/17, at 11:00 a.m. B/S was 144 --08/23/17, at 7:00 a.m. B/S was 124 --08/29/17, at 7:00 a.m. B/S was 127 At 9:47 a.m. on 08/31/17, the DON, compared the recorded blood sugars to the MAR. The DON verified the insulin was administered on the above dates and times, when the insulin should have been held. The DON said a performance improvement plan was started on 07/07/17 to correct the above issue. She said, I thought the problem had been corrected but I guess not. 2. [MEDICATION NAME] and [MEDICATION NAME] The resident was admitted to the facility on [DATE]. On 06/28/17, the physician prescribed [MEDICATION NAME] tablet delayed release 500 mg., give 1 tablet by mouth 2 times a day for yelling/increased agitation related to unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition. On 06/29/17, the physician prescribed [MEDICATION NAME] HCI 50 mg's give 0.5 tablet by mouth three (3) times a day related to restlessness and agitation. The behavior monitoring sheet, attached to the MAR, was ordered on [DATE], to observed the resident for yelling and agitation. At 11:38 a.m. on 08/31/17, the DON was asked why the resident was started on [MEDICATION NAME] and [MEDICATION NAME]. The DON said a nurses note, dated 06/21/17, noted the resident was screaming out on all shifts and pushing the call light for no reason. A nurses note, dated 06/22/17, found the following, RN (Registered Nurse) assessment/LPN (Licensed Practical Nurse) appearance of resident-What I think is going on with the resident is: To be wanting to get up and is tired of lying in bed. He states that he understands that he is not supposed to get up. A nurses note, dated 06/22/17, While this nurse and the CNA (certified nursing assistant) were picking up resident off the floor he started to yell and hit CNA demanding that we get him up right now and put him in his chair. This nurse calmed resident down and explained to him that we do not yell and hit staff. At 12:57 p.m. on 08/31/17, the DON provided a psychoactive medication evaluation, dated 06/28/17, related to the use of [MEDICATION NAME] for yelling/agitation. Ineffective interventions were listed as distraction, relaxation, reassurance, offer activities. The DON was unable to provide how and when these interventions were applied. For example, what activities were offered and when, how was the resident distracted, etc. The DON confirmed the nurses notes only discussed the residents behaviors on 2 dates: 06/21/17 and 06/22/17. The nurses note, dated 06/22/17 noted the nurse was able to calm the resident down. The DON was asked if the facility considered the nursing documentation, The resident is wanting to get up and is tired of lying in bed. He understands that he is not supposed to get up. What did the staff do to allow the resident to get out of bed? The DON was unable to answer this question. At 4:14 p.m. on 09/05/17, the DON was asked if she had any further information to present regarding the use of [MEDICATION NAME] and [MEDICATION NAME] without documentation of non-pharmacological interventions attempted before starting the medications. The DON provide no further information.",2020-09-01
129,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,334,D,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the staff failed to obtain a consent prior to administering the [MEDICAL CONDITION] vaccine in (YEAR) for three (3) of five (5) residents reviewed. Resident identifiers: #19, #95, and #190. Facility census: 180. Findings include: a) Resident #19 According to the Medication Administration Record, [REDACTED]. However, no informed consent was obtained before the [MEDICAL CONDITION] vaccine injection on 10/27/16. b) Resident #95 According to the Medication Administration Record, [REDACTED]. On 09/07/17 at 1:35 p.m., Unit Manager (UM) #87 was unable to locate any documentation that consent for the [MEDICAL CONDITION] vaccine had been obtained from Resident #95 or his representative at any time. c) Resident #190 According to the Medication Administration Record, [REDACTED]. On 09/07/17 at 1:35 p.m., Unit Manager (UM) #87 was unable to locate any documentation that consent for the [MEDICAL CONDITION] vaccine had been obtained from Resident #190 or her representative at any time. According to the facility's policy and procedure entitled Immunizations: Influenza (Flu) Vaccination of Residents, Staff, and Volunteers, Informed consent in the form of a discussion regarding risks and benefits of vaccination will occur prior to vaccination. According to the facility's policy and procedure entitled Standing Orders for Administering Influenza Vaccine to Adults, Provide all patients with a copy of the most current federal Vaccine Information Statement (VIS). You must document in the patient's medical record or office log, the publication date of the VIS and the date it was given to the patient. UM #22 and UM #87 were interviewed on 09/07/17 at 1:35 p.m. UM #22 stated verbal consent was obtained from the resident or the resident's representative prior to administration of the [MEDICAL CONDITION] vaccine. UM #87 stated that written consent is obtained. The Director of Nursing (DoN) was also interviewed on 09/07/17 at 1:35 p.m. The DoN stated consents for the [MEDICAL CONDITION] vaccine are not obtained annually. She stated once consent had been obtained, the vaccine was administered yearly based on this consent.",2020-09-01
130,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,353,E,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, policy review, and observation, the facility failed to ensure qualified nursing staff provided day to day care to meet the resident's needs in an environment which promoted each resident's physical, mental, and psychosocial well-being, to enhance their quality of life. The facility failed to ensure all employees were thoroughly screened prior to employment (Employee #150 was not screened through West Virginia (WV) Cares as required by law.) For Residents #322, #372, #280, #84, #110, #233, #290 and #367's allegations of abuse/neglect was not thoroughly investigated and reported to the appropriate state agencies. For Resident #235, the facility failed to follow physician orders [REDACTED]. For Resident #141, the facility failed to follow physician orders [REDACTED]. For Residents #284 and #336 the facility failed to assess pressure ulcers present on admission. For Resident #382, the facility failed to correlate care and services for a resident receiving [MEDICAL TREATMENT] treatments. For Resident #19, the facility failed to follow physician's guidance to contact the responsible party in regard to completing lab tests. For Resident #19, the facility failed to provide restorative services as ordered by the physician. For Resident #90, the facility failed to have the knowledge needed to provide oral care for a dependent care resident. For Residents #141 and #320, the facility failed to provide the necessary services for each resident to restore and/or maintain the resident's bladder functioning. For Residents #350 and #214, the facility failed to ensure the residents environment was as free of accident hazards as possible. For Resident #320, the facility failed to ensure acceptable parameters of nutrition was maintained. For Resident # 350, the facility failed to administer insulin as ordered. These deficient practices had the potential to affect more than an isolated number of residents. Employee identifier: #150. Resident identifiers: #322, #372, #280, #84, #110, #233, #290, #367, #235, #141, #284, #336, #382, #19, #90, #320, #214, #350 and #320. Facility census: 180. Findings include: a) Resident #382 A review of the information submitted by the facility regarding how many residents in the facility received [MEDICAL TREATMENT] treatment revealed Resident #382 received [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. The physician's orders [REDACTED]. The physician's orders [REDACTED]. On 08/31/17 at 10:05 a.m. Licensed Practical Nurse (LPN) #111 said she was not sure what days the resident attended [MEDICAL TREATMENT] but thought she went in the evening. A second conversation, with LPN #111 on 08/31/17 at 10:37 a.m., revealed LPN #11 felt the resident's [MEDICAL TREATMENT] time slots varied and sometimes she went in the morning and sometimes in the evening. LPN #111 said it depended on whether or not the [MEDICAL TREATMENT] center had a seat for the resident in the mornings. She said they would call in the mornings and let the facility know if the resident could attend in the morning instead of the evening. LPN #111 said they mostly called before 9:00 a.m. A progress note, dated 09/05/17, stated the resident's regularly scheduled time for [MEDICAL TREATMENT] would be Monday, Wednesday, Friday but was subject to change based on the [MEDICAL TREATMENT] center availability. On 08/31/17 at 11:07 a.m. Resident #382 said she had called the dietary department to make sure she got a meal tray at 5:00 p.m. everyday just to make sure she would get it early on the days she attends [MEDICAL TREATMENT]. On 08/31/17 at 11:07 a.m., during an interview with Resident #382, the resident explained that the facility was not doing a very good job regarding the coordination of her care. She said a nurse aide came on the morning of 08/31/17 and asked her if she was ready to get dressed for [MEDICAL TREATMENT]. She said she reminded the nurse aide that she did not attend [MEDICAL TREATMENT] on Thursdays. Resident #382 also said she had concerns over showering because she did not think she could get her Permacath (special catheter inserted in the jugular vein on the neck or upper chest area to aid in [MEDICAL TREATMENT]) wet. She said staff members felt they could cover up the Permacath and give her a shower. On 08/30/17 at 10:00 a.m., during a confidential interview with a registered nurse (RN), the RN said she was not sure if the Permacath could be covered for showering. She also said she was not positive if there were any medications she could not give prior to [MEDICAL TREATMENT]. The RN said she thought she might not be able to give the blood pressure medications prior to [MEDICAL TREATMENT]. Nurse Aide #145, on 08/30/17 at 10:10 a.m., said she thought you could cover the Permacath with a plastic type covering and give the resident a shower. A progress note dated 09/05/17 stated, Due to Permacath, resident should not receive showers and only bed baths should be given The note also indicated that all medications could be given prior to [MEDICAL TREATMENT] with no concerns. 09/05/17 Note Text: Spoke with Debra at [MEDICAL TREATMENT] center to clarify [MEDICAL TREATMENT] order for resident. The Pre/Post Treatment information sheet from a [MEDICAL TREATMENT] treatment on 08/25/17 was not received by the facility until 08/30/17 at 12:06 p.m. Licensed Practical Nurse (LPN) #103 was asked about the Pre/Post [MEDICAL TREATMENT] treatment sheet for 08/25/17 on 08/30/17 at 11:44 a.m. LPN #103 said the [MEDICAL TREATMENT] treatment center did not send this sheet back on 08/25/17 and he had requested they fax it to the facility. He said he was not sure who may have requested it before he did. On 09/05/17 at 12:12 p.m. during an interview with Assistant Director of Nursing (ADON) #40 it was explained that the nursing staff did not have good coordination with the [MEDICAL TREATMENT] center regarding the care for Resident #382. The issues with the confusion over which days and and what time the resident went to [MEDICAL TREATMENT] was discussed as well as the issues with the Permacath, medications and dietary. Following the interview with the ADON, RN #87 telephoned the [MEDICAL TREATMENT] center. The following note was recorded in the resident's medical record, Spoke with (staff name) at [MEDICAL TREATMENT] center to clarify [MEDICAL TREATMENT] order for resident. (Staff name) confirmed that her scheduled time is to be MWF at 1800 but is subject to change based on center's availability. (Name of ambulance company) to transport to all appointment times. (Staff name) also said that all medications could be given prior to the resident arriving at [MEDICAL TREATMENT] with no concerns. Also, due to Permacath, resident should not receive showers and only bed baths should be given. Resident is aware of the above and agrees with all b) Resident #19 On 07/17/17 a laboratory specimen for a renal panel was collected per the physician's orders [REDACTED]. The results of the specimen were reviewed by the physician on 07/17/17. The results indicated the following abnormalities: Sodium was high, Chloride was high, BUN (blood Urea Nitrogen) was high, Glucose was high and Calcium was low. The physician ordered a no added salt diet and directed staff to encourage oral fluids, after reviewing the laboratory results. The physician advised the nurse to contact the resident's responsible party to determine if the responsible party wants repeated laboratory reports. Further review of the resident's Physician order [REDACTED]. Under the heading, Medically Administered Fluids and Nutrition, No Labs, had been hand written under the category of other orders. A straight line had been drawn through, No Labs, and above was hand written D/C 05/20/15. The POST form was unclear as to if the responsible party wanted or did not want any laboratory values drawn. The Director Of Nursing reviewed the laboratory report and the POST form at 10:10 a.m. on 08/30/17. She said she would follow up with the unit manager, Registered Nurse (RN) #116 to see if she contacted the responsible party. At 12:06 p.m. on 08/30/17, the DON said she was unable to find any evidence the responsible party was contacted in regards to obtaining future laboratory values. c) Resident #284 Resident #284 was discharged from the facility to an outside hospital on [DATE] due to lethargy and a general decline in his condition. At the time of his discharge, Resident #284 had a stage IV pressure ulcer on his right heel. He also had a surgical wound on his coccyx where a skin flap procedure had been performed. Resident #284 returned to the facility on [DATE]. The Nursing Admission Data Collection, performed on 08/26/17 at 8:26 p.m., documented the presence of a wound on the back of his right lower leg, in addition to the coccyx wound and the right heel pressure ulcer that were present upon discharge. No description of the right lower leg wound, including measurement and staging, was documented. On 08/28/17 at 5:11 p.m., a Skin - Weekly Pressure Ulcer Record evaluation was performed. A new right lateral calf pressure ulcer was documented. The date of onset was given as 08/26/17, and the pressure ulcer was noted to have been present since admission. The pressure ulcer was described as a Stage III with measurements of 3 cm x 3.2 cm x 1 cm. The wound base was noted to be 100% yellow tissue. Because the right lower leg pressure ulcer had not been assessed upon admission, it cannot be determined whether the wound worsened from the time of admission on 08/26/17 to the time of assessment on 08/28/17. According to the facility's Skin Management policy and procedure with a revision date of (MONTH) (YEAR), Residents admitted with skin impairments will have wound location and characteristics documented in the Nursing admitted Collection Set (UDA). During an interview on 09/05/17 at 4:42 p.m., the Director of Nursing (DoN) stated wound assessment was not performed by the nurse completing the admission assessment. The wound care nurse performed assessment of wounds and pressure ulcers, including measurement and staging, in order to ensure consistency. Resident #284 was readmitted to the facility on [DATE], which was a Saturday. The wound care nurse was not in the facility on the weekend. The wound care nurse assessed Resident 284's wounds when she returned to the facility on Monday, 08/28/17. The DoN stated the Skin Management policy and procedure with a revision date of (MONTH) (YEAR) was the current policy and procedure. d) Resident #336 Medical record review, on 09/06/17 at 11:10 a.m., for Resident #336 revealed she was admitted on [DATE] after a hospitalization . Review of the Nursing Admission Data Collection Form, indicated the resident had open areas on her coccyx, left, and right buttock. No measurements or description of the open areas could be found. On 05/20/17 at 1:54 a.m., a Nursing Initial care Plan was completed. This care plan found a focus Potential breakdown. Goal: Resident's skin will remain intact without signs of breakdown by next review. Interventions included, Provide wound care/preventative skin care per order and Skin checks weekly per facility protocol, document findings. Review of daily skilled note on 05/20/17 at 3:55 p.m., revealed no skin issues documented. Additional medical record review found initial pressure ulcer record dated 05/22/17 at 1:47 p.m., which revealed Resident # 336 had a total of three (3) pressure ulcers as follows: --Left buttocks- unstageable and measured 4 centimeter (cm) in length and 4 cm in width, depth unknown due to 50% of yellow tissue and 50% purple tissue in wound base. --Coccyx-unstageable and measured 2 cm in length and 1.5 cm in width, depth unknown due to 75% red tissue and 25% purple tissue in wound base. --Right buttocks- unstageable and measured 1.5 cm in length and 1.5 cm in width , depth unknown due to 30% red tissue, 30% yellow tissue and 40% purple tissue in wound base. Physician orders [REDACTED]. During an interview with the Director of Nursing (DON) on 09/07/17 at 12:15 p.m., she verified there was not any documentation by the nursing staff concerning the size, staging and treatments for the resident's pressure ulcers until 05/22/17, three (3) days after admission to the facility. She reviewed the chart and confirmed even though no measurements, staging and treatments were written, the facility claimed the three (3) pressure ulcers were present on admission. She also confirmed there was no documentation to show if the pressure ulcers had changed since admission on 05/19/17. e) Resident #235 1. Aspirin A review of Resident #235's medical record at 9:44 a.m. on 09/06/17 found the following physician order [REDACTED]. Increase ASA (Aspirin) dose to 325 mg (milligrams) 1 po (by mouth) qd (every day) for PE (pulmonary embolism). CBC (completed blood count) 1 wk (week). Review of Resident #235's Medication Administration Record [REDACTED]. In fact Resident #235 has received Aspirin 81 mg daily since 01/05/17 with no change in dosage. An interview with the interim Director of Nursing (DON) at 2:41 p.m. on 09/06/17 confirmed Resident #235's aspirin dose was never increased as the physician order [REDACTED]. 2. Pain Management A review of Resident #235's medical record at 9:44 a.m. on 09/06/17 found the following physician note dated 02/21/17 which read under the section titled, Plan: For Chronic pai[DIAGNOSES REDACTED] continue biofreeze . Further review of the record found a physician order [REDACTED]. This order has remained in effect since 01/09/17 it was revised on 03/29/17 to read as follows: Biofreeze Liquid (Menthol(Topical [MEDICATION NAME]) Apply to bilateral legs topically every four (4) hours for pain. An interview with Resident #235 and her husband at 12:30 p.m. on 09/06/17 revealed Resident #235 often experiences pain in her legs and her feet. When asked what helps with the pain she stated, Biofreeze helps the most. She continued, But I don't always get it like I am supposed to and my legs and feet will hurt. She stated, When I have the biofreeze I do not have to ask for pain medication because the biofreeze takes care of my pain. Review of the Treatment Administration Record (TAR) from 02/01/17 through 09/05/17 found the following days and times when Resident #235 did not receive her biofreeze. Unless otherwise noted the MAR indicated [REDACTED] --02/02/17 at 12:00 a.m. and 4:00 a.m. --02/04/17 at 12:00 a.m. and 4:00 a.m. --02/05/17 at 4:00 a.m. --02/08/17 and 02/09/17 at 12:00 a.m. and 4:00 a.m. --02/12/17 at 12:00 a.m., 4:00 a.m., 8:00 a.m. and 12:00 p.m. --02/13/17 at 4:00 p.m. and 8:00 p.m. --02/14/17 at 12:00 a.m. and 4:00 a.m. --02/15/17 at 12:00 a.m., 4:00 a.m., 4:00 p.m. and 8:00 p.m. --02/17/17 at 12:00 a.m., 4:00 a.m., and 8:00 p.m. --02/18/17 at 12:00 a.m. and 4:00 a.m. --02/19/17 at 4:00 p.m. and 8:00 p.m. --02/21/17 at 12:00 a.m. and 4:00 a.m. --02/24/17, 02/25/17, and 02/26/17 at 4:00 p.m. and 8:00 p.m. Unless otherwise noted the MAR indicated [REDACTED] --03/03/17 at 12:00 a.m. and 4:00 a.m. --03/08/17 and 03/10/17 at 8:00 p.m. --03/11/17 at 12:00 a.m. and 4:00 a.m. --03/13/17 at 4:00 a.m. --03/14/17 at 8:00 p.m. --03/16/17 at 8:00 a.m. and 12:00 p.m. --03/18/17 at 4:00 a.m. --03/19/17 at 12:00 p.m. --03/20/17 at 8:00 a.m. and 12:00 p.m. --03/21/17 at 12:00 a.m. and 4:00 a.m. --03/25/17 at 8:00 p.m. --03/27/17 at 4:00 p.m. and 8:00 p.m. --03/29/17 at 4:00 a.m., 4:00 p.m., and 8:00 p.m. --03/30/17 at 12:00 a.m. and 4:00 a.m. --03/31/17 at 8:00 a.m. and 12:00 p.m. Unless otherwise noted the MAR indicated [REDACTED] --04/01/17 at 8:00 p.m. --04/03/17 at 4:00 p.m. and 8:00 p.m. --04/04/17 at 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m. --04/14/17 at 8:00 a.m. and 12:00 p.m. --04/15/17 at 4:00 a.m. --04/16/17 at 12:00 a.m., 4:00 a.m., 4:00 p.m. and 8:00 p.m. --04/17/17 at 8:00 p.m. --04/18/17 at 12:00 a.m., 4:00 a.m., 8:00 a.m., and 12:00 p.m. --04/22/17 at 12:00 a.m. and 4:00 a.m. --04/23/17 at 12:00 p.m., 4:00 p.m. and 8:00 p.m. --04/24/17 at 12:00 a.m. and 4:00 a.m. Unless otherwise noted the MAR indicated [REDACTED] --05/04/17 at 12:00 p.m. --05/08/17 at 8:00 p.m. --05/13/17 at 8:00 p.m. --05/19/17 at 8:00 a.m. and 12:00 p.m. --05/20/17 at 12:00 p.m. --05/21/17 at 4:00 a.m. --On 05/22/17 at 12:00 a.m., 4:00 a.m., 8:00 a.m., and 12:00 p.m. Progress notes indicated the Biofreeze was not available and they were awaiting its arrival. --05/27/17 at 4:00 a.m., and 8:00 p.m. --Resident was in the hospital from 05/29/17 through 06/05/17. Unless otherwise noted the MAR indicated [REDACTED] --06/10/17 at 4:00 a.m. and 8:00 p.m. --06/11/17 at 8:00 p.m. --06/14/17 at 4:00 a.m., 8:00 a.m. and 12:00 p.m. --06/15/17 at 4:00 a.m. Unless otherwise noted the MAR indicated [REDACTED] --07/05/17 ay 8:00 p.m. --07/10/17 at 4:00 p.m. and 8:00 p.m. --07/14/17 at 4:00 p.m. and 8:00 p.m. --07/26/17 at 4:00 p.m. and 8:00 p.m. --07/30/17 at 4:00 a.m. Unless otherwise noted the MAR indicated [REDACTED] --08/02/17 at 4:00 a.m. --08/08/17 at 4:00 p.m. --08/26/17 at 4:00 a.m. During an interview with the Interim DON at 2:41 p.m. on 09/06/17, the above findings were reviewed with her. She indicated that they appear to have a documentation problem and that the TAR should not be left blank. She stated it should have a check mark or a code number indicating why the treatment was not administered. f) Resident # 141 A review of Resident #141's medical record at 8:41 a.m. on 08/31/17 found the following physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. For the [MEDICATION NAME] the MAR indicated [REDACTED]. Review of the progress note dated 05/27/17 at 4:58 p.m. indicated the medication was not administered because they were awaiting its arrival from the pharmacy. An interview with the Interim DON at 11:27 a.m. on 08/31/17 confirmed Resident #141 did not receive the ordered dose of [MEDICATION NAME]. She indicated that she called the pharmacy and it was delivered to the facility on [DATE] at 7:08 p.m. but the nurse had already entered the note and there was no indication in the medical record that the medication was ever administered to Resident #141. g) Resident #19 On 08/22/17, the physical therapist referred the resident to the facility's restorative program. On 08/24/17, the resident began the following restorative program: The goal for restorative therapy was: Maintain strength and functional mobility level Activities to be performed for restorative: 1. Stretching to Bilateral hamstrings and bilateral gastrocnemius muscles 30-45 second hold. (MONTH) do in seated or supine position 2. Therapeutic exercises for bilateral lower extremities ankle pumps, heel slides straight leg raises, hip abduction/adduction and hip flexions long arc quads, 2 sets of 10 reps; may do in seated or supine. 3. Wheel chair mobility 50-100 feet Bilateral upper extremities and bilateral lower extremities for propulsion, min Assistance to SBA (stand by assistance); instruct patient on safe turning of wheel chair, safe negotiation of obstacles and correct upper extremity and lower extremity placement. At 2:19 p.m. on 08/30/17, the unit manager, Registered Nurse (RN) #116 said the restorative aides keep paper documentation of restorative services provided to residents. RN #116 said the resident had not received any therapy and she did not know why. RN #116 called Restorative Aide (RA) #33 to review the restorative therapy services. RA #33 said the resident had not had any therapy because a second aide who normally works this floor had not been working due to an injury. RA #33 said she had not been on this floor since last Thursday because she had been pulled to the floor to work as a nursing assistant. At 12:50 p.m. on 09/05/17, RN #116 was asked if the second restorative aide had returned to work. She said the RA was in the dining room today. An interview with the second RA #42 at 1:05 p.m. on 09/05/17, found he was in the dining room assisting with lunch. RA #42 said he was on light duty so he would not be able to work with Resident #19. At 1:10 p.m. RA #33 said she worked the floor yesterday so she did not get to see the resident. She stated, I last saw her on 08/31/17 and she refused her therapy. The resident was seen only one (1) time between 08/24/17 and 08/31/17. The resident had not received restorative therapy during the month of September, according to RA #33. The DON confirmed, Resident #19 was not receiving her restorative therapy as ordered on [DATE] at 4:17 p.m. after review of the Rehabilitation/Restorative Service Delivery Record. At 4:17 p.m. on 09/05/17, the administrator confirmed RA #42 was injured on the job, sometime last week. h) Resident #90 Observation of the resident's oral cavity at 10:41 a.m. on 08/29/17, found the resident had what appeared to be her own teeth. Some were missing, discolored and were covered with a white, chalky substance that appeared to be plaque. Observation of the resident's oral cavity with the Registered Nurse (RN) unit manager, at 12:57 p.m. on 09/05/17, found RN #116 discovered the resident had an upper partial and, What looks like a cavity on the lower back tooth. The resident said she had a partial. She stated, I am not going to show it to you because you might steal it. Three (3) nursing assistants (NA's) #47, #5 and #58, (all working on the resident's unit) and RN #116 denied knowing the resident had a partial at 1:21 p.m. on 09/05/17. All denied removing the partial for cleaning. RN #116 was asked if she could find any evidence the facility was ever aware the resident had a partial or any documentation the partial had been removed for cleaning. Record review found the resident was admitted to the facility on [DATE]. The most recent minimum data set (MDS), a quarterly, with an assessment reference date (ARD) of 06/29/17 notes the resident requires extensive assistance of 1 staff member for personal hygiene, which includes brushing teeth. Review of the last 3 nursing monthly assessments, dated 06/12/17, 07/12/17, and 08/12/17 noted the resident has her own teeth under the section entitled, Dentition. The form also allowed the nurse completing the assessment to note the resident had a Partial(s) Bridge(s). This section was not completed, indicating the resident did not have a partial. At approximately 3:00 p.m. on 09/05/17, the Registered Nurse (RN), Resident Care Manager, #3, provided a progress note from a local dentist. She said the family had requested a dental appointment during the resident's care plan meeting. She said the resident did not cooperate and a follow up appointment was going to be scheduled when the family could attend. She said this was the only dental consult she could find for the resident. The dental consult, dated 08/02/17 noted: Patient barely opened mouth for exam. Patient states she does wear a partial on the MX (maxillary) however was unable to have her remove it. There was gross amount of plaque present. Patient will require [MEDICATION NAME] and a more comprehensive exam. Review of the resident's MDS Kardex Report for the nursing assistants found documentation an upper partial had been added to the Kardex on 09/05/17. At 4:16 p.m. on 09/05/17, the Director of Nursing confirmed she had no further information to present regarding the resident's oral status. i) Resident #320 Review of Resident #320's medical record at 8/30/17 at 12:25 p.m., found: MDS Findings: Section H' Bladder and Bowel 4/29/17: H0300. Urinary Continence: *2. Frequently Incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent-voiding) 5/8/17: H0300. Urinary Continence: *2. Frequently Incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent-voiding) 5/22/17: H0300. Urinary Continence: 3. Always Incontinent (no episodes of continent voiding) 6/17/17: H0300. Urinary Continence: *2. Frequently Incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent-voiding) 7/22/17: H0300. Urinary Continence: 3. Always Incontinent (no episodes of continent voiding) Review of Braden Scale for Predicting Pressure Sore Risk: 04/22/2017 at 2:18 p.m. 2. Moisture: Degree to which skin is exposed to moisture: 3. Occasionally Moist: Skin is occasionally moist, requiring an extra linen change approximately once a day. (3 pts.) 04/25/2017 at 4:24 p.m. 2. Moisture: Degree to which skin is exposed to moisture: 1. Constantly Moist: Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. (1 pt.) 05/02/2017 at 4:24 p.m. 2. Moisture: Degree to which skin is exposed to moisture: 2. Very Moist: Skin is often, but not always moist. Linen must be changed at least once a shift. (2 pts.) 05/09/2017 at 4:24 p.m. 2. Moisture: Degree to which skin is exposed to moisture: 3. Occasionally Moist: Skin is occasionally moist, reqiring an extra linen change approximately once a day. (3 pts.) 06/16/2017 at 9:43 a.m. 2. Moisture: Degree to which skin is exposed to moisture: 3. Occasionally Moist: Skin is occasionally moist, reqiring an extra linen change approximately once a day. (3 pts.) A Verbal physician's orders [REDACTED]. Confirmed by Employee #1. The above order was discontinued by telephone on 05/05/2017 at 3:08 p.m. Confirmed by Employee #81. A Telephone physician's orders [REDACTED].#81. Review of Treatment Administration Record 05/01/2017-05/31/2017 included the following: Cleanse bilateral buttocks, coccyx, and sacrum with warm soapy water, rinse, pat dry, apply [MEDICATION NAME] cream topically and prn every shift for increased risk for skin break down. -Order Date 04/25/2017 at 4:33 p.m. -D/C Date 05/05/2017 at 2:55 p.m. Cleanse bilateral buttocks, coccyx and sacrum with warm soapy water. Rinse and pat dry-apply [MEDICATION NAME] cream topically every shift. -Order Date 05/05/2017 at 2:55 p.m. -D/C Date 07/10/2017 at 8:18 a.m. Wash coccyx with warm, soapy water, rinse, pat dry, apply [MEDICATION NAME] q shift and prn every shift for prevention. -Order Date 04/22/2017 at 6:59 p.m. -D/C Date 05/05/2017 at 3:08 p.m. Cleanse bilateral buttocks, coccyx and sacrum with warm soapy water. Rinse and pat dry-apply [MEDICATION NAME] cream topically as needed for increased risk for skin breakdown. -Order Date 05/05/2017 at 2:55 p.m. -D/C Date 07/10/2017 at 8:18 a.m. Review of Treatment Administration Record 06/01/2017-06/30/2017 included the following: Cleanse bilateral buttocks, coccyx and sacrum with warm soapy water. Rinse and pat dry-apply [MEDICATION NAME] cream topically every shift. -Order Date 05/05/2017 at 2:55 p.m. -D/C Date 07/10/2017 at 8:18 a.m. Cleanse bilateral buttocks, coccyx and sacrum with warm soapy water. Rinse and pat dry-apply [MEDICATION NAME] cream topically as needed for increased risk for skin breakdown. -Order Date 05/05/2017 at 2:55 p.m. -D/C Date 07/10/2017 at 8:18 a.m. Review of Treatment Administration Record 07/01/2017-07/31/2017 included the following: Cleanse bilateral buttocks, coccyx and sacrum with warm soapy water. Rinse and pat dry-apply [MEDICATION NAME] cream topically every shift. -Order Date 05/05/2017 at 2:55 p.m. -D/C Date 07/10/2017 at 8:18 a.m. Cleanse bilateral buttocks, coccyx, scrotum, and sacrum with warm soapy water. Rinse and pat dry- apply [MEDICATION NAME] cream topically every shift. -Order Date 07/10/2017 at 8:18 p.m. Cleanse scrotum with warm soapy water, rinse, pat dry, and apply [MEDICATION NAME] every shift. -Order Date 07/01/2017 at 5:03 a.m. -D/C Date 07/10/2017 at 8:17 a.m. Cleanse bilateral buttocks, coccyx and sacrum with warm soapy water. Rinse and pat dry -apply [MEDICATION NAME] cream topically as needed for increased risk for skin breakdown. -Order Date 05/05/2017 at 2:55 p.m. -D/C Date 07/10/2017 at 8:18 a.m. Cleanse bilateral buttocks, coccyx, scrotum, and sacrum with warm soapy water. Rinse and pat dry- apply [MEDICATION NAME] cream topically as needed for increased risk for skin breakdown. -Order Date 07/10/2017 at 8:18 p.m. Review of Treatment Administration Record 08/01/2017-08/31/2017 included the following: Cleanse bilateral buttocks, coccyx, scrotum, and sacrum with warm soapy water. Rinse and pat dry- apply [MEDICATION NAME] cream topically every shift. -Order Date 07/10/2017 at 8:18 p.m. Cleanse bilateral buttocks, coccyx, scrotum, and sacrum with warm soapy water. Rinse and pat dry- apply [MEDICATION NAME] cream topically as needed for increased risk for skin breakdown. -Order Date 07/10/2017 at 8:18 p.m. Review of the Nursing Daily Skilled Charting-V 1: (4/22/17, 4/24/17, 4/25/17, 4/26/17, 4/27/17, 4/28/17, 4/29/17, 4/30/17, 5/1/17, 5/2/17, 5/3/17, 5/4/17, 5/5/17, 5/6/17, 5/7/17, 5/8/17, 5/9/17, 5/10/17, 5/11/17, 5/12/17 and 5/27/17) F. GU/BLADDER: 1 b. Bladder Continence: b. INCONTINENT (Total 21 Days) Review of the Nursing Daily Skilled Charting-V 1: (5/13/17, 5/14/17, 5/15/17, 5/16/17, 5/17/17, 5/18/17, 5/19/17, 5/21/17, 5/22/17, 5/23/17, 5/24/17, 5/25/17, 5/26/17, 5/29/17, 5/30/17 and 5/31/17) F. GU/BLADDER: 1 b. Bladder Continence: a. CONTINENT (Total 16 Days) Review of the Nursing Daily Skilled Charting-V 1: (6/9/17,6/12/17, 6/13/17, 6/26/17 and 6/27/17) F. GU/BLADDER: 1 b. Bladder Continence: b. INCONTINENT (Total 5 Days) Review of the Nursing Daily Skilled Charting-V 1: (6/1/17, 6/2/17, 6/4/17, 6/5/17, 6/6/17, 6/7/17, 6/8/17, 6/10/17, 6/11/17, 6/14/17, 6/15/17, 6/17/17, 6/18/17, 6/19/17, 6/20/17, 6/21/17, 6/22/17, 6/23/17, 6/24/17, 6/25/17, 6/28/18, 6/29/17 and 6/30/17) F. GU/BLADDER: 1 b. Bladder Continence: a. CONTINENT (Total 23 Days) Review of the Nursing Daily Skilled Charting-V 1: (7/2/17, 7/3/17, 7/4/17, 7/10/17, 7/17/17, 7/18/17, 7/19/17, 7/20/17, 7/21/17, 7/22/17, 7/23/17, 7/24/17, 7/25/17, 7/26/17, 7/27/17, 7/28/17, 7/29/17 (TRUNCATED)",2020-09-01
131,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,356,B,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure the nurse staff posting contained the correct date. This practice had the potential to effect more than a limited number of residents and or family members wishing to view the posting. Facility census: 180. Findings include: a) Staff posting Upon entrance to the facility for the initial tour, at 11:14 a.m. on 08/28/18, observation found the staff nursing posting was dated 08/27/17. Employee #104, the [MEDICAL CONDITION] program manager, confirmed the date on the posting was incorrect. Employee #111, a Licensed Practice Nurse (LPN) said she put the incorrect date in error because she had been working all night. The staff posting was corrected immediately. At 1:26 p.m. on 09/06/17, the administrator was advised of the above findings. The administrator provided no comment.",2020-09-01
132,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,362,E,0,1,QLZ111,"Based on observation and staff interview the facility failed to ensure one (1) resident observed through random opportunity received the lunch meal on 08/28/17 in a timely manner. Resident #85 received her tray 50 minutes after trays were delivered on her floor. Resident identifier: #85. Facility census: 180. Findings include: a) Resident #85 On 08/28/17 at 1:00 p.m. an observation revealed Resident #85 in her room in bed. She appeared to be sleeping. Her eyes were closed. Lunch trays were delivered to fourth floor and were passed to residents at 1:00 p.m. on 08/28/17. Continued observations of Resident #85 continued until 1:30 p.m. on 08/28/17. The observations revealed the resident did not have a lunch tray and remained in bed with her eyes closed. At 1:30 p.m. Licensed Practical Nurse (LPN) #55 was asked if Resident #55 would be getting a lunch tray. LPN #55 said Resident #85 typically ate in the dining room and they had asked for her tray to be brought to fourth floor. At 1:50 p.m. on 08/28/17, LPN #131 delivered Resident #85's tray. On 09/06/17 at 4:26 p.m. the district director of clinical services stated the facility staff could have been trying to get the resident to attend dining in the dining room and that could have caused the delay in delivering her tray.",2020-09-01
133,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,412,D,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family interview, staff interview, and record review, the facility failed to provide a medicaid resident routine dental services when the resident lost her dentures. This was true for one (1) of three (3) residents reviewed for dental care during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #19. Facility census: 180. Findings include: a) Resident #19 During a telephone interview with the resident's responsible party at 9:56 a.m. on 08/29/17, the responsible party expressed concern because the resident's bottom dentures were missing. The responsible party said she was unsure how long the dentures had been missing. The responsible party stated she could not afford to replace the dentures and the facility did not offer to assist with replacing the dentures. At 10:27 a.m. on 08/29/17 the resident was observed in her room without any upper or lower dentures and no natural teeth. At 12:10 p.m. on 08/30/17, Employee #15, the social services manager, said she was unaware the resident's bottom denture was missing. She stated the admission agreement specifies the facility does not replace lost or missing items. At 12:20 p.m. on 08/30/17, the resident was observed to be up in her wheelchair sitting at the nurses station. She had no lower or upper dentures. At 2:23 p.m. on 08/30/17, the unit charge nurse, Registered Nurse (RN) #116 was asked if the resident had dentures. She stated, I knew she had uppers and apparently they are missing now. I just found out, we are looking for them. An interview with the resident's nursing assistant, (NA) # ///, at 2:29 p.m. on 08/30/17 found she knew the resident had upper dentures. I don't know how long they have been missing, I don't remember the last time I saw them. At 2:35 p.m. on 08/30/17 an interview with [NAME] #15 found she was unaware the residents upper dentures were now missing. When asked if the facility arranges for financial assistance to replace the dentures, she stated, We haven't in the past. She verified she was unaware of any appointments made in the past to explore replacing the lower dentures. Review of the resident's personal inventory sheet, completed upon her admission to the facility on [DATE], noted the resident was admitted with both upper and lower dentures. A second personal inventory sheet, completed on 05/21/15, noted the resident only had upper dentures. At 11:28 a.m. on 09/05/17, the Director of nursing was asked if the facility had located the resident's upper dentures. The DON stated the upper dentures had not been located at 4:22 p.m. on 09/05/17. At the same time, the administrator stated if the dentures were affecting her ability to eat she could be sent to see a dentist.",2020-09-01
134,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,425,E,0,1,QLZ111,"Based on observation and staff interview, the facility failed to ensure that expired medication was not administered to residents. One (1) of three (3) residents observed during medication administration was found to have an expired medication. Resident identifier: #103. Facility census: 180. Findings include: a) Resident #103 Medication administration was observed for Resident #103 on 08/30/17 at 8:55 a.m. Sertraline Hydrochloride, an antidepressant, 100 mg every day was ordered for Resident #103. The medication was supplied in a pack containing thirty (30) individual blisters. Each individual blister contained one (1) tablet. The medication expiration date was printed on the front of the pack. The medication expiration date was also printed on the back of each blister. The medication expiration date was 07/31/17, indicating that the medication was expired. The pharmacy label affixed on the front of the pack indicated that the medication had been supplied to the facility by the pharmacy on 08/17/17. Nine (9) of the tablets from the individual blisters were missing, having been dispensed to Resident #103 on previous days. The medication administration to Resident #103 was performed by Licensed Practical Nurse (LPN) #176. On 08/30/17 at 8:55 a.m., LPN #176 agreed the Sertraline Hydrochloride for Resident #103 had expired on 07/31/17. On 08/30/17 at 9:00 a.m., Unit Manager (UM) #22 also agreed the Sertraline Hydrochloride for Resident #103 had expired on 07/31/17. UM #22 also stated that all medications in the medication cart would be audited to ensure that no other medications were expired. UM #22 obtained Sertraline Hydrochloride 100 mg with a current expiration date from the facility's medication dispensing system, and this tablet was administered to Resident #103. During an interview on 08/30/17 at 2:00 p.m., the Director of Nursing stated she had already been notified by nursing staff about the expired Sertraline Hydrochloride for Resident #103.",2020-09-01
135,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,428,D,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the pharmacist identified and reported irregularities during the monthly medication regimen review for one (1) of six (6) residents reviewed for unnecessary medications. The pharmacist did not identify Resident #350's insulin was not administered according to physician's orders [REDACTED].#350. Facility census: 180. Findings include: a) Resident #350 The resident was admitted to the facility on [DATE]. Review of the resident's (MONTH) Medication Administration Record [REDACTED] Novolog Flex Pen Solution Pen-injector 100 units (ML (insulin Aspart). Inject 10 units subcutaneously before meals related to Type 2 Diabetes Mellitus with Hyperglycemia, hold for Blood sugar (BS) less than 150. Order date 08/03/17. On 08/22/17 the order was changed to Novolog Flex pen Solution Pen-Injector 100 unit/ML (insulin Aspart). Inject 5 units subcutaneously before meals related to Type 2 Diabetes Mellitus with Hyperglycemia, hold for blood sugar less than 150. Novolog was administered on the following ten (10) dates and times when the resident's blood sugar (BS) was less than 150: --08/05/17, at 5:00 p.m., BS was 148. --08/07/17, at 7:00 a.m. BS was 122 --08/09/17, at 7:00 a.m. BS was 130 --08/13/17, at 7:00 p.m. BS 147 --08/14/17, at 7:00 a.m. BS was 127 --08/17/17, at 7:00 a.m. BS was 112 --08/19/17, at 11:00 a.m. BS was 146 --08/20/17, at 11:00 a.m. BS was 144 --08/23/17, at 7:00 a.m. BS was 124 --08/29/17, at 7:00 a.m. BS was 127 At 9:47 a.m. on 08/31/17, the DON, compared the recorded blood sugars to the MAR. The DON verified the insulin was administered on the above dates and times, when the insulin should have been held. The DON said a performance improvement plan was started on 07/07/17 to correct the above issue. She said, I thought the problem had been corrected but I guess not. On 08/16/17, the pharmacist completed a monthly medication regimen review and reported no irregularities. The resident's insulin was administered incorrectly on five (5) occasions before the monthly medication review. At 4:14 p.m. on 09/05/17, the DON verified the pharmacist failed to identify this irregularity during his 08/16/17 review of the resident's medications.",2020-09-01
136,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,441,E,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to follow infection control practices to prevent the spread of disease. Staff failed to provide a barrier between a box and bottle of medication and the bedside table for Resident #103, who was one (1) of three (3) residents observed during medication administration. Additionally, beverages were left uncovered on a cart in the hallway before distribution to residents. This practice had the potential to affect more than a limited number of residents. Resident identifier: #103. Facility census: 180. Findings include: a) Resident #103 Licensed Practical Nurse (LPN) #176 was observed during morning medication administration on 08/30/17. Resident #103 was ordered [MEDICATION NAME], a nasal spray supplied in a bottle intended for multiple uses by the resident. The [MEDICATION NAME] nasal spray bottle is contained in a box. On 08/13/17 at 8:55 a.m., LPN #176 removed the [MEDICATION NAME] box from the medication cart. She carried the box into Resident #103's room. LPN #176 removed the [MEDICATION NAME] bottle from the box, and placed both the box and the bottle directly on Resident 103's bedside table. She did not place a barrier between the [MEDICATION NAME] box and bottle and the bedside table. Resident #103 declined [MEDICATION NAME] administration. LPN #176 placed the [MEDICATION NAME] bottle back into the box, and then placed the box back into the medication cart. During an interview with LPN #176 at 9:00 a.m., she stated she should have used a barrier, such as a paper towel, between the [MEDICATION NAME] box and bottle and Resident #103's bedside table. On 08/30/17 at 2:00 p.m., the Director of Nursing was notified of the above findings. b) Noontime meal observation On 08/28/17 at 12:30 p.m., two surveyors performed meal observation of residents on the fourth floor. At 12:30 p.m., beverages in uncovered glasses were noted on a cart in the hallway. The beverages remained uncovered on the cart in the hallway until 1:00 p.m. At 1:00 p.m., the lunch trays for fourth floor residents arrived. The trays were distributed to the residents, along with the beverages that had been uncovered in the hallway for at least thirty minutes. During an observation on 09/05/17 at 12:00 p.m., beverages on a cart on the fourth floor were noted to be in pitchers covered with plastic wrap. The beverages were poured into glasses immediately before being served to residents along with their meal trays. On 09/06/17 at 4:24 p.m., the District Director of Clinical Services was notified of the observations made on 08/28/17 and 09/05/17. She stated beverages to be served with meals arrive from the kitchen in pitchers covered with plastic wrap. She also stated the beverages were probably pre-poured into the glasses on the unit on 08/28/17, and then the meal trays arrived later than expected.",2020-09-01
137,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,463,D,0,1,QLZ111,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure one (1) of 40 residents had a functioning call light system. Resident identifier: #84. Facility census: 180. Findings include: a) Resident #84 08/29/17 at 11:51 a.m. Resident #84's call light was observed not functioning. It did not light up above the resident's door when the button was pushed. Resident #84 did have the ability to use the call light. Nurse Aide #134 verified this light was not working. Resident #84's brief interview for mental status (BIMS) completed on the admission minimum data set ((MDS) dated [DATE] revealed the resident's BIMS score as 15. A score of 15 indicated the resident was cognitively intact.,2020-09-01
138,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,465,D,0,1,QLZ111,"Based on observation and staff interview the facility failed to ensure the heating and air conditioning unit in one (1) of 38 rooms observed during Stage 1 of the quality indicator survey (QIS) was in good repair. The heating/air condition unit in Room #409 had broken vents in the top of the unit. Room number: #409. Facility census: 180. Findings include: a) Room #409 On 08/29/17 at 2:39 p.m. an observation of the heat/air unit in Room #409 revealed the unit had broken vents in the top. The entire section of the top of the unit where the heat/air unit was missing. During an observation with Maintenance Supervisor #34, on 08/30/17 at 10:24 a.m., he agreed the unit needed replaced.",2020-09-01
139,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,497,D,0,1,QLZ111,"Based on staff interview, observation, and review of employee personnel records, the facility failed to ensure a performance review was completed every twelve (12) months for two (2) of five (5) nurse aides reviewed during the extended survey. Employee identifiers: #74 and #126. Facility census: 180. Findings include: a) Review of personnel files At 10:58 a.m. on 09/07/17, the Director of Nursing (DON) and the Human Resources Director, #183, confirmed Nurse Aides (NA's) #74 and #126 did not have a performance review completed within the past twelve (12) months.",2020-09-01
140,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,498,F,0,1,QLZ111,"Based on staff interview and employee personnel files review, the facility failed to ensure five (5) of five (5) nurse aides (NA) were able to demonstrate competency in skills and techniques necessary to care for residents' needs. Employees: #56, #74, #126, #131, and #99. Facility census: 180. Findings include: a) Personnel Records Review At 2:00 p.m. on 09/06/17, review of the active employee list provided by the facility, found the following employees and their dates of hire: --NA #56, hire date, 04/24/15; --NA #74, hire date, 08/27/15; --NA #126, hire date, 09/15/14; --NA #131, hire date, 09/15/14; --NA #99, hire date, 10/02/12. At 2:56 p.m. on 09/06/2017, the director of nursing (DON) confirmed the facility did not have any documentation to substantiate nurse aides had demonstrated competency in skills necessary to provide daily resident care. The DON said she had realized this was an issue last week and she had started a performance improvement plan.",2020-09-01
141,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,502,D,0,1,QLZ111,"**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 laboratory test for Resident #235. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey. Resident Identifiers: #235. Facility Census: 180. Findings Include: a) Resident #235 A review of Resident #235's medical record at 9:24 a.m. on 09/06/17 found the following physician progress notes [REDACTED]. Plan: For Pneumonia- completed [MEDICATION NAME] 2 days ago. Cough and Congestion have improved. Will Continue [MEDICATION NAME] for 5 more days and monitor. EXG - NSR, [MEDICAL CONDITION] resolved at this time but will continue to monitor heart rate. Will Check CBC (complete blood count) and CMP in the AM. The Interim Director of Nursing (DON) shortly after this review was asked to provide the results of the CBC and CMP which should have been obtained on 06/23/17. At 11:46 a.m. on 09/06/17 the interim DON reported she did not have the requested lab results. She stated, there was never an order put in for it and they never obtained it.",2020-09-01
142,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,514,D,0,1,QLZ111,"Based on record review and staff interview, the facility failed to ensure the resident's medical record was correct in the area of Health Care Surrogate (HCS) and whom to notify when Resident #84 experienced a change which would require notification of the appropriate responsible party. The facility had conflicting contact information on Resident #84's face sheet concerning responsible party. Resident identifier: #84. Facility census: 180. Findings include: a) Resident #84 Review of Resident #84's face sheet, on 09/06/17 at 9:00 a.m, found under section titled, Contacts , the residents daughter was listed as the first contact and it was indicated she was the Power of Attorney (POA) and his son was listed as secondary contact. Further review found a HCS selection form completed 06/05/17, by the attending physician, designating the son as the HCS. No further HCS designation forms could be located in the medical records. Additionally, the daughter is not his PO[NAME] Interview with Employee #122, social worker (SW), on 09/06/17 at 9:15 a.m., revealed she thought the daughter was the HCS on admission and had asked to appoint her brother the HCS due to personal issues. When asked, Is there another HCS designation form. She replied, I don't see any in the medical records. On 09/06/17 at 11:00 a.m., Employee #122, SW, provided this surveyor with a HCS designation form dated 05/30/17. She further confirmed this form had been faxed to her on 09/06/17 at 10:35 a.m. This HCS form indicated the Daughter was in fact appointed as the HCS while the resident was in the hospital. However, this HCS became void when the attending physician at the facility appointed Resident #84's son as the HCS on 06/05/17. The facility continued to notify Resident #84's daughter of changes in her condition and had the daughter listed as the health care decision make on the resident face sheet even after Resident #84's son was appointed HCS on 06/05/17 and Resident #84 does not have a power of attorney.",2020-09-01
143,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,520,E,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, policy review, observation, and employee personnel record review the facility failed to ensure that there Quality Assessment and Assurance (QA & A) committee identified and corrected quality deficiencies in which it did have knowledge of or should have had knowledge of. This failure has the potential to effect more than an isolated number of residents. Resident Identifiers: Resident #87, #307, #286, #256, #229, #224, #322, #372, #280, #84, #110, #233, #290, #367, #19, #121, #284, #336, and #382. Employee Identifiers: #150, #74, #126, #56, #131, and #99. Facility Census: 180. Findings Include: a) Facility Management of Personal Funds Review of residents' personal funds account, on 09/06/17 at 2:25 p.m., found five (5) residents had personal funds within $200.00 dollars of the $2,000.00 dollar limit allowed for residents receiving Medicaid benefits. Review of resident individual account balances for 08/06/17 found the following residents within $200.00 dollars of the $2,000.00 dollar limits: --Resident #307- $1,802.10 --Resident #286- $1980.45 --Resident #256- $2,204.38 --Resident #229- $1,907.79 Further review of resident individual account balances for 09/05/17 found the following residents within $200.00 dollars of the $2,000.00 dollar limits: --Resident #224- $2,103.15 --Resident #229- $2,209.79 Upon interview on 09/07/17, at 9:20 a.m., with the Business Office Manager (BOM), she found the computer generated notice when the resident's personal funds reaches $1,800.00 dollar limit. She further confirmed she was unaware she was to provide the notice to the residents and/or responsible party until the corporate offices informed her of the responsibility of printing and providing the resident and/or the responsible party today (09/07/17). On 09/07/17 at 10:25 a.m., the Director of Nursing (DON) and the Nursing Home Administrator (NHA) was both notified. No further information was provided. b) Investigate Individuals and Report Allegations 1. WV CARES West Virginia Code 16-49-9 established new criminal background check requirements for applicants for employment as direct access personnel in long-term care facilities. Effective 08/01/15, all nursing home facilities were required to .prescreen all direct access personnel applicants considered for hire for negative findings by way of an Internet search of registries and licensure databases through the WV Cares website. WV CARES is administered by the Department of Health and Human Resources and the WV State Police Criminal Investigation Bureau (CIB) in consultation with the Centers for Medicare and Medicaid Services (CMS), the Department of Justice (DOJ) and the Federal Bureau of Investigation (FBI). The program uses web-based technologies to provide employers a single portal for checking state and national abuse registries and the state and national sex offender registries. The web-based system also provides employers access to Nurse Aide Registries for all 50 states and professional licensure registries where available. The web based system provides an efficient and effective means for an employer to check an applicant's status prior to paying the cost of a criminal history background check. Through fingerprinting, this program provides a comprehensive criminal history records search of national and state criminal history records that was not available under the previous reliance on name-based record searches. The program relies on new technology to monitor criminal histories and alert officials when a subsequent change in criminal history occurs (i.e., rapback) A monitored criminal history record means the cost of re-fingerprinting is not required for employees who change employers in this industry (or apply for work at more than one employer) within the timeframe of a valid background check. All fitness determinations will be performed by WV CARES who have cleared state and federal background check requirements. Employers will receive a notice of the applicants employment eligibility once the fingerprint based background check results are received. At 8:48 a.m. on 08/30/17 a Notification of Eligible Fitness Determination letter from WV Cares was requested for Employee #150 who was hired in the dietary department on 04/10/17. At 11:47 a.m. on 08/30/17 Employee #183, the area human resource manager, stated that they did not have a WV Cares Notification of Eligible Fitness Determination letter for Employee #150. She stated that she was finger printed on 04/05/17 by MorphoTrust but that the results were never sent to WV Cares. She indicated she did not realize that they had not been sent to WV CARES until she went to pull it from the WV CARES system when it was requested by the surveyor on 08/30/17. 2. Resident #322 A review of the reportable incidents beginning at 10:40 a.m. on 08/30/17 found an Immediate Fax Reporting of Allegations - Nursing Home Program completed on 07/27/17 listing Resident #322 as the alleged victim. On the form under the section titled, Brief Description of the Incident the following was hand written: (typed at written) Resident alleges (unidentified) CNA (Certified Nursing Assistant) is rude, yells, and cusses at him and he alleges this CNA told him that they were not going to change him every 2 (two) hours. Review of the five - day follow up pertaining to this allegation completed by Licensed Practical Nurse (LPN) Social Service Manager (SSM) #15 found the following: (typed as written) I spoke with the resident and he told me that the CNA was (first name of Nurse Aide (NA) #13) . I spoke with the CNA (first and last name of NA #13) who told me she recall the evening and stated in fact the resident was the one who was cussing and screaming and she stated she immediately went out and told the co worker what had happened. During an interview with LPN - SSM #15 beginning at 3:35 p.m. on 08/30/17 in regards to this allegation she stated this was not reported to the Nurse Aide Program after a Nurse Aide was identified because she spoke with Resident #322 and he had stated the NA just needed to be fine tuned and therefore she did not feel it was substantiated so she did not report it to the Nurse Aide Program. 3. Resident #372 A review of the reportable incidents beginning at 10:40 a.m. on 08/30/17 found an Immediate Fax Reporting of Allegations - Nursing Home Program completed on 08/01/17 listing Resident #372 as the alleged victim. On the form under the section titled, Brief Description of the Incident the following was typed: (typed as written) The residents son alleges the following: Resident has had a decline in status and wont do anything, call light not answered timely, alleges waited 3 1/2 hours to be changed after a bowel movement and pain medication it not effective enough. Review of the five - day follow up pertaining to this allegation completed by LPN - SSM #15 found the following: (typed as written) . In regards to allegation of having a bowel movement and waiting 3 hours to be changed. he states this was Saturday into Sunday from 4:30 a.m. to 8:00 a.m During an interview with LPN-SSM #15 beginning at 3:35 p.m. on 08/30/17, when asked if once the resident gave her a specific time frame if she reported the Nurse Aide who was assigned to him during this time frame to the Nurse Aide Program as an alleged perpetrator she stated, No because the allegation was not substantiated therefore I did not report it to the Nurse Aide Program. She further stated, Maybe I should have done that. 4. Resident #280 A review of the reportable incidents beginning at 10:40 a.m. on 08/30/17 found an Immediate Fax Reporting of Allegations - Nursing Home Program completed on 07/26/17 listing Resident #280 as the alleged victim. On the form under the section titled, Brief Description of the Incident the following was hand written: (typed as written) Resident alleged CNA took her to the shower room and during the time in the shower alleges CNA left shower and told her she had to get another resident off the bedpan - states CNA was gone less than five minutes and no issues occurred . Review of the five - day follow up pertaining to this allegation completed by LPN - SSM #15 found the following: (typed as written) After interviewing the resident, it was found the date she is alleging was 07/17/17. It was also found out that the CNA was (First and Last Name of NA #145). I spoke with (First Name of NA #145) regarding this allegation and she reports she does remember this day and she took the resident to the shower and it was very hot in the shower room. She stated that (First name of Resident #280) was safely in her chair and she told the resident she was going to open the first door to the shower room to catch her breath and she would be able to hear her (stating it was just a few feet away) During an interview with LPN-SSM #15 beginning at 3:35 p.m. on 08/30/17, when asked if once the Nurse Aide was identified if this allegation was then reported to the Nurse Aide Program she stated, No it was not, because it was unsubstantiated so I did not think to report it. 5. Resident #84 A review of the complaints and concerns beginning at 12:00 p.m. on 08/30/17 found a concern form dated 06/19/17 which identified Resident #84 as the Resident involved. Under the section titled, Description of Concern the following was hand written: (typed as written) Daughter states he did not get shower, toothbrush or water pitcher from Saturday until Wednesday. Feels like they left him up too long in his wheelchair on Wednesday. Review of the reportable incidents for the month (MONTH) (YEAR) found no reportable incident related to concern voiced by Resident #84's daughter. During an interview with LPN-SSM #15 beginning at 3:35 p.m. on 08/30/17, when asked if this allegation was reported as an allegation of neglect she stated, No because I pulled the ADL (Activities of Daily Living) flow sheet report immediately and the daughter was fine with that. 6. Resident #110 A review of the complaints and concerns beginning at 12:00 p.m. on 08/30/17 found a concern form dated 07/15/17 which identified Resident #110 as the resident involved. Under the section titled, Description of Concern the following was hand written: (typed as written) Resident stated she had been asking since lunch time to be cleaned up. Went into room at 3:45 p.m. to change dressing and resident voiced concern about not being cleaned. CNA went into room to clean up resident at this time. Resident states this is not the first time. Resident room partner stated yellow ring around the residents sheet. Review of the reportable incidents for the month of (MONTH) (YEAR) found no reportable incident related to concern voiced by Resident #110. An interview with the Nursing Home Administrator (NHA) at 4:21 p.m. on 08/30/17, confirmed he was the person who handled this concern for Resident #110. When asked if this concern had been reported as an allegation of neglect he stated, No because after doing further interviews he did not feel like it was a reportable incident. 7. Resident #233 A review of the complaints and concerns beginning at 12:00 p.m. on 08/30/17 found a concern form dated 07/17/17 which identified Resident #233 as the resident involved. Under the section titled, Description of Concern the following was hand written: (typed as written) Resident reports that the weekend was terrible and her got into an argument with RCS - (First name of RCS) on 4 occasions. Reports a very bad attitude - that she put him down on Saturday as refusing a bath and he did not refuse. She would not make his bed how he asked her too. She fuss with me every time she to come into my room. My roommate laid in a dirt brief from breakfast to noon yesterday. They would come in and turn light off and would not change him. Finally around noon he got changed. Last night (Sunday after Midnight) I put my call light on and it took 40 minutes to get someone in here. Review of the reportable incidents for the month of (MONTH) (YEAR) found no reportable incident related to this concern voiced by Resident #233. An interview with the NHA at 4:11 p.m. on 08/30/17 confirmed this concern was not reported as an allegation of abuse and/or neglect. He indicated after he finished up his investigation he did not feel it was substantiated therefore he did not report it. 8. Resident #290 A review of the complaints and concerns beginning at 12:00 p.m. on 08/30/17 found a concern form dated 07/16/17 which identified Resident #290 as the resident involved. Under the section titled, Description of Concern the following was hand written: (typed as written) Husband states nurse forced her to take medicine, among other issues. Wants to talk to administrator . Review of the reportable incidents for the month of (MONTH) (YEAR) found no reportable incident related to this concern voiced by Resident #290. An interview with the NHA at 4:19 p.m. on 08/30/17, confirmed this allegation of abuse was not reported. He stated that after he talked to Resident #290's husband it was clear the nurse was just adamant that the resident take her medicine and she did not force her to take it. He indicated that is why he did not report this allegation of abuse. 9. Resident #367 On 08/29/17 at 11:14 a.m., during a Stage 1 interview of the QIS survey, Resident #96 said a female resident across the hall from him had yelled for 30 minutes needing a bed pan. Resident #96 did not know if the other resident's call light was on. Resident #96 also did not know if this resident ever received assistance. During an interview with Administrator #107, on 09/07/17 at 10:38 am., he said he did have knowledge of this issue and had spoken with Resident #96 and had identified Resident #367 as the resident who needed assistance. During the interview, on 09/07/17 at 10:38 a.m., Administrator #107 provided hand written notes dated 08/21/17. The notes reflect Administrator #107's conversation with Resident #96 and Resident #367. Resident #367 was identified as having a [DIAGNOSES REDACTED].#107's conversation with Resident #367 the resident denied having any issues with needing a bedpan the night before. The administrator noted the resident had a catheter, was on a toileting plan and was care planned for yelling out and turning call light on continuously. Administrator #107 said he had not interviewed any staff regarding this issue nor had he identified this as an allegation of neglect. He also confirmed he had not reported this issue to the appropriate outside State agencies. He said he did not report this issue because after speaking with the resident and obtaining information from other sources he concluded the resident had not been neglected. 10. Policy Review A review of the facility's Abuse and Neglect Prohibition Policy with revision date of (MONTH) (YEAR), on 08/30/17 at 9:00 a.m., found the following under the section titled Reporting and Response: 1. The facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of property to the administrator, State Survey Agency, and law enforcement officials and Adult Protective Services (where state law provides for jurisdiction in long term care facilities) in accordance with state law through established procedures. Timeline for reporting is as follows: a. If the events that caused the allegation involve abuse or result in serious bodily injury, a report is made no later than 2 hours after the management staff becomes aware of allegation. b. If the events that cause the allegation do not involve abuse and do not result in serious bodily injury a report is made not later than 24 hours after the management team become aware of the allegation 3. The facility will report any occurrences of abuse by licensed or certified staff and any knowledge it has of actions by a court of law against an employee , which would indicate unfitness for employment to the applicable state board in accordance with the state law. c) Develop and Implement Abuse/Neglect Policies Policy Development: a. Dementia Management and Resident Abuse Prevention. A review of the facility's Abuse and Neglect Prohibition policy with a revision date of (MONTH) (YEAR), at 9:00 a.m. on 08/30/17 found the following pertaining to the training of employees: 1. The facility will train each employee on this policy during orientation, annually, and more often as determined by the facility. 2. The facility will provide training regarding related policies and procedures. 3. The facility will provide education for those individuals involved with the resident (i.e. family responsible party or legal representative, visitors.) Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities revision 168, with a revision date of 03/08/17 found the following, F226 ** (Rev. 168, Issued: 03-08-17, Effective: 03-08-17, Implementation: 03-08-17) 483.12(b) The facility must develop and implement written policies and procedures that . (3) Include training as required at paragraph 483.95 . 483.95(c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in 483.12, facilities must also provide training to their staff that at a minimum educates staff on- 483.95(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at 483.12. 483.95(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property 483.95(c)(3) Dementia management and resident abuse prevention. 483.95(c)(1) and 483.95(c)(2) are covered in the facility's policy which the facility indicates they will train the staff, however 483.95(c)(3) dementia management and resident abuse prevention is not contained in the policy. These findings were discussed with the Nursing Home Administrator (NHA) at 9:22 a.m. on 08/31/17. He stated that he would have to make sure this was the most recent policy they had in place. At 9:32 a.m. on 08/31/17 the NHA stated that this was the most recent policy they had. He confirmed dementia management and resident abuse prevention was not contained in this policy as required. Reporting and Response: A review of the facility's Abuse and Neglect Prohibition Policy with revision date of (MONTH) (YEAR), on 08/30/17 at 9:00 a.m., found the following under the section titled Reporting and Response: 1. The facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of property to the administrator, State Survey Agency, and law enforcement officials and Adult Protective Services (where state law provides for jurisdiction in long term care facilities) in accordance with state law through established procedures. Timeline for reporting is as follows: a. If the events that caused the allegation involve abuse or result in serious bodily injury, a report is made no later than 2 hours after the management staff becomes aware of allegation. b. If the events that cause the allegation do not involve abuse and do not result in serious bodily injury a report is made not later than 24 hours after the management team becomes aware of the allegation 3. The facility will report any occurrences of abuse by licensed or certified staff and any knowledge it has of actions by a court of law against an employee , which would indicate unfitness for employment to the applicable state board in accordance with the state law. Review of the State Operations Manual (SOM) Appendix PP - Guidance to Surveyors for Long Term Care Facilities revision 168, with a revision date of 03/08/17 found the following in regards to F225 and reporting of allegations: 483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. The SOM specifies that reporting is to be done within 2 hours or 24 hours depending on the circumstances after the allegation is made not after the management team has been made aware of the allegation. These findings were discussed with the Nursing Home Administrator (NHA) at 9:22 a.m. on 08/31/17. He stated that he would have to make sure this was the most recent policy they had in place. At 9:32 a.m. on 08/31/17 the NHA stated that this was the most recent policy they had. He confirmed their policy indicating the reporting times began after the management team was made aware of the allegation. He stated we always have a manger here and staff are to immediately report to the manager any allegations or abuse or neglect to get the process started. 2. Policy Implementation in regards to reporting of alleged abuse and or neglect, A review of the facility's Abuse and Neglect Prohibition Policy with revision date of (MONTH) (YEAR), on 08/30/17 at 9:00 a.m., found the following under the section titled Reporting and Response: 1. The facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of property to the administrator, State Survey Agency, and law enforcement officials and Adult Protective Services (where state law provides for jurisdiction in long term care facilities) in accordance with state law through established procedures . Timeline for reporting is as follows: a. If the events that caused the allegation involve abuse or result in serious bodily injury, a report is made no later than 2 hours after the management staff becomes aware of allegation. b. If the events that cause the allegation do not involve abuse and do not result in serious bodily injury a report is made not later than 24 hours after the management team become aware of the allegation. 3. The facility will report any occurrences of abuse by licensed or certified staff and any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for employment to the applicable state board in accordance with the state law. The following instances were found where the facility failed to implement their policy related to reporting and response: 3. Resident #322 A review of the reportable incidents beginning at 10:40 a.m. on 08/30/17 found an Immediate Fax Reporting of Allegations - Nursing Home Program completed on 07/27/17 listing Resident #322 as the alleged victim. On the form under the section titled, Brief Description of the Incident the following was hand written: (typed at written) Resident alleges (unidentified) CNA (Certified Nursing Assistant) is rude, yells, and cusses at him and he alleges this CNA told him that they were not going to change him every 2 (two) hours. Review of the five - day follow up pertaining to this allegation completed by Licensed Practical Nurse (LPN) Social Service Manager (SSM) #15 found the following: (typed as written) I spoke with the resident and he told me that the CNA was (first name of Nurse Aide (NA) #13) . I spoke with the CNA (first and last name of NA #13) who told me she recall the evening and stated in fact the resident was the one who was cussing and screaming and she stated she immediately went out and told the co worker what had happened. During an interview with LPN - SSM #15 beginning at 3:35 p.m. on 08/30/17 in regards to this allegation she stated this was not reported to the Nurse Aide Program after a Nurse Aide was identified because she spoke with Resident #322 and he had stated the NA just needed to be fine tuned and therefore she did not feel it was substantiated so she did not report it to the Nurse Aide Program. 4. Resident #372 A review of the reportable incidents beginning at 10:40 a.m. on 08/30/17 found an Immediate Fax Reporting of Allegations - Nursing Home Program completed on 08/01/17 listing Resident #372 as the alleged victim. On the form under the section titled, Brief Description of the Incident the following was typed: (typed as written) The residents son alleges the following: Resident has had a decline in status and wont do anything, call light not answered timely, alleges waited 3 1/2 hours to be changed after a bowel movement and pain medication it not effective enough. Review of the five - day follow up pertaining to this allegation completed by LPN - SSM #15 found the following: (typed as written) . In regards to allegation of having a bowel movement and waiting 3 hours to be changed. he states this was Saturday into Sunday from 4:30 a.m. to 8:00 a.m During an interview with LPN-SSM #15 beginning at 3:35 p.m. on 08/30/17, when asked if once the resident gave her a specific time frame if she reported the Nurse Aide who was assigned to him during this time frame to the Nurse Aide Program as an alleged perpetrator she stated, No because the allegation was not substantiated therefore I did not report it to the Nurse Aide Program. She further stated, Maybe I should have done that. 5. Resident #280 A review of the reportable incidents beginning at 10:40 a.m. on 08/30/17 found an Immediate Fax Reporting of Allegations - Nursing Home Program completed on 07/26/17 listing Resident #280 as the alleged victim. On the form under the section titled, Brief Description of the Incident the following was hand written: (typed as written) Resident alleged CNA took her to the shower room and during the time in the shower alleges CNA left shower and told her she had to get another resident off the bedpan - states CNA was gone less than five minutes and no issues occurred . Review of the five - day follow up pertaining to this allegation completed by LPN - SSM #15 found the following: (typed as written) After interviewing the resident, it was found the date she is alleging was 07/17/17. It was also found out that the CNA was (First and Last Name of NA #145). I spoke with (First Name of NA #145) regarding this allegation and she reports she does remember this day and she took the resident to the shower and it was very hot in the shower room. She stated that (First name of Resident #280) was safely in her chair and she told the resident she was going to open the first door to the shower room to catch her breath and she would be able to hear her (stating it was just a few feet away) During an interview with LPN-SSM #15 beginning at 3:35 p.m. on 08/30/17, when asked if once the Nurse Aide was identified if this allegation was then reported to the Nurse Aide Program she stated, No it was not, because it was unsubstantiated so I did not think to report it. 6. Resident #84 A review of the complaints and concerns beginning at 12:00 p.m. on 08/30/17 found a concern form dated 06/19/17 which identified Resident #84 as the Resident involved. Under the section titled, Description of Concern the following was hand written: (typed as written) Daughter states he did not get shower, toothbrush or water pitcher from Saturday until Wednesday. Feels like they left him up too long in his wheelchair on Wednesday. Review of the reportable incidents for the month (MONTH) (YEAR) found no reportable incident related to concern voiced by Resident #84's daughter. During an interview with LPN-SSM #15 beginning at 3:35 p.m. on 08/30/17, when asked if this allegation was reported as an allegation of neglect she stated, No because I pulled the ADL (Activities of Daily Living) flow sheet report immediately and the daughter was fine with that. 7. Resident #110 A review of the complaints and concerns beginning at 12:00 p.m. on 08/30/17 found a concern form dated 07/15/17 which identified Resident #110 as the resident involved. Under the section titled, Description of Concern the following was hand written: (typed as written) Resident stated she had been asking since lunch time to be cleaned up. Went into room at 3:45 p.m. to change dressing and resident voiced concern about not being cleaned. CNA went into room to clean up resident at this time. Resident states this is not the first time. Resident room partner stated yellow ring around the residents sheet. Review of the reportable incidents for the month of (MONTH) (YEAR) found no reportable incident related to concern voiced by Resident #110. An interview with the Nursing Home Administrator (NHA) at 4:21 p.m. on 08/30/17, confirmed he was the person who handled this concern for Resident #110. When asked if this concern had been reported as an allegation of neglect he stated, No because after doing further interviews he did not feel like it was a reportable incident. 8. Resident #233 A review of the complaints and concerns beginning at 12:00 p.m. on 08/30/17 found a concern form dated 07/17/17 which identified Resident #233 as the resident involved. Under the section titled, Description of Concern the following was hand written: (typed as written) Resident reports that the weekend was terrible and her got into an argument with RCS - (First name of RCS) on 4 occasions. Reports a very bad attitude - that she put him down on Saturday as refusing a bath and he did not refuse. She would not make his bed how he asked her too. She fuss with me every time she to come into my room. My roommate laid in a dirt brief from breakfast to noon yesterday. They would come in and turn light off and would not change him. Finally around noon her got changed. Last night (Sunday after Midnight) I put my call light on and it took 40 minutes to get someone in here. Review of the reportable incidents for the month of (MONTH) (YEAR) found no reportable incident related to this concern voiced by Resident #233. An interview with the NHA at 4:11 p.m. on 08/30/17 confirmed this concern was not reported as an allegation of abuse and/or neglect. He indicated after he finished up his investigation he did not feel it was substantiated therefore he did not report it. 9. Resident #290 A review of the complaints and concerns beginning at 12:00 p.m. on 08/30/17 found a concern form dated 07/16/17 which identified Resident #290 as the resident involved. Under the section titled, Description of Concern the following was hand written: (typed as written) Husband states nurse forced her to take medicine, among other issues. Wants to talk to administrator . Review of the reportable incidents for the month of (MONTH) (YEAR) found no reportable incident related to this concern voiced by Resident #290. An interview with the NHA at 4:19 p.m. on 08/30/17, confirmed this allegation of abuse was not reported. He stated that after he talked to Resident #290's husband it was clear the nurse was just adamant that the resident take her medicine and she did not force her to take it. He indicated that is why he did not report this allegation of abuse. 10. Resident #367 On 08/29/17 at 11:14 a.m., durin (TRUNCATED)",2020-09-01
144,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,550,E,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to treat each resident with respect and dignity for 4 out of 35 residents. For Residents #104, #94, and #9, the facility failed to provide a dignified dining experience. For Resident #177, the facility failed to provide privacy when administering an injection. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #104, #94, #9, and #177. Facility census 182. Findings included: a) Resident #104 On 10/07/19 at 12:30 PM, resident meal delivery / tray pass began on the OB Park unit. On 10/07/19 at 12:40 PM, Resident #104 had not received a tray. On 10/07/19 at 12:54 PM, Resident #104's tray was delivered. During an interview on 10/07/19 at 12:55 PM, Employee #199 was asked why Resident #104 did not receive a tray during the initial meal delivery on the unit. Employee #199 stated I can't tell you why he didn't get his tray with everyone else. The tray must have been shoved up too high and the staff didn't see it. On 10/09/19 at 8:22 AM, an interview with the Administrator and the Director of Nursing (DON) did not reveal any further information. b) Resident #94 On 10/07/19 at 12:30 PM, resident meal delivery / tray pass began on the OB Park unit. On 10/07/19 at 12:37 PM, Resident #94 had not received a tray. During an interview on 10/07/19 at 12:55 PM, Employee #199 was asked why another resident (Resident #104) had not received a tray. Employee #199 stated that the other resident (Resident #104) had been given a tray. During this interview, Employee #199 was asked if all residents now had their meals and trays delivered. Employee #199 stated that they had. The surveyor noted to Employee #199 that Resident #94 still had not received his tray. Employee #199 stated that she did not know that Resident #94 had not received a tray. Resident #94's tray was delivered on 10/07/19 at 1:02 PM. On 10/09/19 at 8:22 AM, an interview with the Administrator and the Director of Nursing (DON) did not reveal any further information. c) Resident #9 On 10/07/19 at 12:30 PM, resident meal delivery / tray pass began on the OB Park unit. On 10/07/19 at 12:38 PM, Resident #9 had not received a tray. During an interview on 10/07/19 at 12:55 PM, Employee #199 was asked why another resident (Resident #104) had not received a tray. Employee #199 stated that the other resident (Resident #104) had been given a tray. During this interview, Employee #199 was asked if all residents now had their meals and trays delivered. Employee #199 stated that they had. The surveyor noted to Employee #199 that Resident #9 still had not received his tray. Employee #199 stated that she did not know that Resident #9 had not received a tray. Resident #9's tray was delivered on 10/07/19 at 12:59 PM. On 10/09/19 at 8:22 AM, an interview with the Administrator and the Director of Nursing (DON) did not reveal any further information. d) Resident #177 During an observation of medication administration on 10/09/19 at 7:46 AM, Licensed Practical Nurse (LPN) # 185 was administration an injection of [MEDICATION NAME] 20 mg (used for the treatment for [REDACTED]. LPN #185 entered the room of Resident #185, she did not knock on the door, before entering. She asked Resident #185 where he wanted his injection. He said, in his normal spot. She opened the privacy curtain. Without closing the door or the privacy curtain, she pulled his shirt up exposing his abdomen, and administrated the medication. During an interview on 10/09/19 at 7:57 AM, LPN #185 was asked if she normally would have knocked on the door, closed the door and curtain before providing treatment? She stated, that she should have. On 10/10/19 at 9:30 AM, during an interview with Administrator and Director of Nursing, they were informed of the observations for Resident #177. They had no comments.",2020-09-01
145,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,578,E,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure that each resident's Physician order [REDACTED]. This failed practice had the potential to affect all residents residing at the facility. Resident identifiers: #125, #139, #9, #95, #108, and #137. Facility census: 182. Findings included: a) Resident #125 Review of Resident #125's medical records found a POST form completed and signed by the attending physician on [DATE]. No signature and/or verbal consent documented on the POST form. Interview with the Director of Nursing (DON) on [DATE] at 2:00 pm, confirmed there was no resident/family signature on the POST form dated [DATE]. b) Resident #139 Review of Resident #139's medical records found a POST form completed and signed by the attending physician and verbal consent given on [DATE]. The POST form was inaccurately marked to attempt resuscitation/CPR and comfort measures. Interview with the Director of Nursing (DON) on [DATE] at 2:00 pm, confirmed the POST form dated [DATE] was inaccurately noted the resident should have been marked Do Not Resuscitate/DNR. c) Resident #137 Review of Resident #137's physician's orders [REDACTED].N. (Registered Nurse) may pronounce death - (MONTH) have IV fluids for trial period no longer than 3 days - No feeding tube. Review of Resident #137's medical records revealed a Physician order [REDACTED]. During an interview on [DATE] at 2:57 PM, the Director of Nursing and the District DIrector of Clinical Services were informed Resident #137's most recent POST form did not correspond with the current physician's orders [REDACTED]. On [DATE] at 4:03 PM, the administrator was notified of the situation. During an interview on [DATE] at 3:00 PM, the Director of Nursing stated the order had been corrected. d) Resident #108 During a review of Resident #108's medical record on [DATE] at 9:34 AM Resident #108's physician orders [REDACTED].#108's preferences for intravenous (IV) fluids or a feeding tube. However, Resident #108's physician's orders [REDACTED]. The above findings were discussed with the facility's Director of Nursing (DoN) as well as District Director of Clinical Services on [DATE] at 2:50 PM. The DoN acknowledged that Resident #108's POST form and orders did not match. No further information was provided prior to exit. e) Resident #9 On [DATE] at 8:36 AM, a record review of the resident's chart on the unit revealed that there was a Physician order [REDACTED]. The POST form is an advanced directive, indicating resident / resident representative's wishes. The POST form was signed by Resident #9's medical power of attorney (MPOA) / healthcare surrogate / resident representative on [DATE]. As of [DATE], Resident #9's POST form had not been signed by a physician. According to the POST form, Resident #9 was supposed to be a Do No Attempt Resuscitation (DNR), comfort measures, intravenous (IV) fluids for a trial period to be determined, and a feeding tube long term. Employee #199 verified that the POST form had not been signed by a physician. On [DATE] at 8:22 AM, the findings were discussed with the Administrator and the Director of Nursing (DON) and no further information was provided f) Resident #95 On [DATE] at 8:36 AM, a record review of the resident's chart on the unit revealed that there was a Physician order [REDACTED]. The POST form is an advanced directive, indicating resident / resident representative's wishes. The POST form was signed by Resident #95's medical power of attorney (MPOA) / healthcare surrogate / resident representative on [DATE]. As of [DATE], Resident #9's POST form had not been signed by a physician. According to the POST form, Resident #95 was supposed to be attempt Cardiopulmonary Resuscitation (CPR), full interventions, intravenous (IV) fluids for a trial period to be determined, and a feeding tube to be determined at time of need. Employee #199 verified that the POST form had not been signed by a physician. On [DATE] at 8:22 AM, the findings were discussed with the Administrator and the Director of Nursing (DON) and no further information was provided.",2020-09-01
146,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,584,D,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide a safe, sanitary, and homelike environment. Resident #9 had an order for [REDACTED]. Resident identifier: #9. Facility census: 182. Findings included: a) Resident #9 On 10/07/19 at 4:13 PM, during an observation of Resident #9's room, the fall mat located near the bathroom, was noted to have fluid underneath the entire length of the fall mat. Moreover, the fall mat located on the right side of Resident #9's bed had debris underneath the fall mat. The fall mat on the left side of Resident #9's bed had fluid underneath the fall mat, spanning the length of the mat. The floor underneath the fall mat was white, and discolored. On 10/07/19 at 4:15 PM, Employee #81, Unit Manger, entered Resident #9's room and observed the fluid underneath two fall mats and the debris underneath the third fall mat. Employee #81 stated that she would notify housekeeping. On 10/07/19 at 4:24 PM, the Director of Nursing (DON) and the District Director of Clinical Services were informed of the findings. On 10/09/19 at 2:06 PM, the findings were discussed with the Administrator and the DON and no further information was provided",2020-09-01
147,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,605,D,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure all residents were free from chemical restraint for purposes of discipline or staff convenience for 2 out of 35 sampled residents. This failed practice had the potential to affect a limited number of residents. Identified Resident identifiers: #161, and #9. Facility census 182. Findings included: a) Resident #161 During a review of medical records for Resident #161 on 10/08/19 at 12:30 PM, revealed his care plan had the following intervention: --Resident #161 receives antipsychotic medication-- [MEDICATION NAME]-- for refusal of care/mood changes. This was initiated on 03/20/18. During an interview on 10/10/19 at 9:45 AM, Director of Nursing agreed, he should not be given a medication for refusal of care, and that it was his right to refuse showering/bathing. b) Resident #9 Review of the medical record revealed a current order, dated 08/05/19 for [MEDICATION NAME] 200 mg given at bedtime for refusal of care related to [MEDICAL CONDITION] disorder, recurrent, and unspecified. Review of the care plan found the resident refuses to wear his identification bracelet. The care plan also noted that the resident would refuse incontinent care. The care plan referenced the use of an anti-anxiety medication and said the resident refused care related to anxiety but the specific care refused was not documented. On 10/10/19 at 11:26 AM, the findings were discussed with the Administrator and the Director of Nursing (DON). No further information was provided to indicated what type of care the resident refused, prior to the survey conclusion. There was no evidence provided to verify the resident refused any type of care.",2020-09-01
148,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,623,D,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical review and staff interview, the facility failed to notify the Ombudsman when Residents #94, #119, and #95 were transferred to a local hospital. This was true for two (2) of three (3) residents reviewed for hospital transfers and one (1) random opportunity for discovery. Resident identifiers: #94, #119, and #95. Facility census 182. Findings included: a) Resident #94 Record review on 10/07/19 at 8:19 PM, revealed the resident was discharged to the hospital on [DATE] at 11:13 AM, due to abnormal labs. b) Resident #119 Record review on 10/07/19 at 8:19 PM, revealed the resident was discharged to the hospital on [DATE] at 6:45 PM, due to abnormal and critical lab work. c) Resident #95 Record review on 10/08/19 at 9:04 AM, revealed the resident was discharged to the hospital on [DATE] at 7:25 PM, per resident and family request. d) Interviews On 10/08/19 at 1:20 PM, the Administrator stated the Social Worker completes the notifications to the Ombudsman regarding facility-initiated discharges. During an interview on 10/08/19 at 1:21 PM, Employee #126, Social Services Manager, stated the facility sends the discharge notifications to the Ombudsman every time a resident leaves the facility. Employee #126 was asked to provide the Ombudsman notification for Resident #94, #119, and #95 when each resident was transferred to a local hospital. Employee #126 stated that the facility does not notify the Ombudsman when a resident is discharged to the hospital. The facility only notifies the Ombudsman when the resident discharges to home or is transferred to another facility. On 10/09/19 at 8:22 AM, the findings were discussed with the Administrator and the Director of Nursing (DON).",2020-09-01
149,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,625,D,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical review and staff interview, the facility failed to provide the resident/resident representative notice of the bed hold policy when Resident #95 was transferred to a local hospital. This was true for one (1) of three (3) residents reviewed for hospital transfers. Resident identifier: #95. Facility census 182. Findings include: a) Resident #95 During a medical record review, on 10/08/19, it was discovered that Resident #95 was transferred to a local hospital on [DATE] at 7:25 PM. There was no evidence the resident or the residents representative received a copy of the bed hold policy at the time of transfer. In addition there was no documentation in the medical record of contacting the resident / resident representative regarding the bed hold policy. During a record review on 10/08/19 at 1:47 PM, a copy of the bed hold notice could not be located on Resident #95's chart on the unit or in the thinned medical record. On 10/08/19 at 3:57 PM, the chart was given to the Director of Nursing (DON) for review to see if the bed hold notice could be located. The DON was unable to locate the bed hold notice. During an interview with the DON on 10/08/19 at 4:11 PM, the DON stated that she could not find the transfer form with the stamp that indicated that the notice of bed hold policy was provided upon discharge. The findings were discussed with the DON and Administrator on 10/09/19 at 8:22 AM and no further information was provided.",2020-09-01
150,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,641,D,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure accurately completed assessment for Resident #151 reflecting urinary catheterization for 1 of 35 sampled residents. This practice had the potential to affect a limited number of residents. Resident identifiers: R#151 Facility census: 181. Findings included: a) Resident #151 Review of records, on 10/08/19 at 12:28 PM, revealed Resident (R#151) was admitted on [DATE]. Review of the 5-day minimum data set (MDS) with an assessment reference date (ARD) 09/17/19 revealed the MDS was marked indicating an indwelling catheter and intermittent catheterization. Review of orders revealed an order Straight Cath resident if greater than 300 ml (milliliter) residual leave catheter in and follow up with provider . Physician was notified R#151 had 500 ml of output when catheter was initially inserted, an order was given to leave as an indwelling catheter. According to the National Library of Medicine, 'intermittent catheterization' is the insertion and removal of a catheter several times a day to empty the bladder. This type of catheterization is used to drain urine from a bladder that is not emptying adequately. Intermittent catheters are only used at certain times and they are removed right after the urine is drained. On 10/09/19 at 09:54 AM, an interview and review of records with Resident Care Management Director (RCMD#165) responsible for developing MDSs, revealed R#151's 5-day MDS was in error. RCMD#165 verified R#151's 5-day MDS should only have been marked indwelling catheter. Indwelling catheter due to when intermittent catheterization was first attempted the resident had 500 cc of urine drained and the catheter was not removed but remained indwelling and was attached to a closed drainage system as ordered.",2020-09-01
151,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,657,D,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to revise care plans regarding falls, behaviors, and Total [MEDICATION NAME] Nutrition (TPN). This was true for two (2) out of thirty-five (35) resident's care plans reviewed. This failed practice had the potential to affect a limited number of residents. Resident identifiers: R#116 and R#94. Facility census: 181. Findings included: a) Resident (R#116) 1. Falls Review of resident (R#116)'s recent annual minimum data set (MDS) with an assessment reference date (ARD) 09/06/19, on 10/08/19 at 03:53 PM, revealed the following. The resident's Brief Interview for Mental Status (BIMS) score is 3 indicating the resident has a severe cognitive impairment. The resident did not have any behaviors during the 7 day look back period. R#116 needs extensive assistance with all activities of daily living and has range of motion impairments on both sides of his upper and lower extremities. The resident has an indwelling catheter and is continent of bowels. Some pertinent [DIAGNOSES REDACTED]. The resident takes Antipsychotic medication daily. The resident has history of falls and currently participates in occupational therapy services. Review of records, on 10/08/19 at 04:23 PM, revealed the resident had an unwitnessed fall in the courtyard on 08/19/19. The resident fell out of his wheelchair bending forward to retrieve an item off the ground. The resident suffered an abrasion above the right eye on 08/19/19. Approximately a month later, on 09/12/19, the resident again fell out of wheelchair in courtyard reaching forward to pick something up off the ground, causing an abrasion to the back of his left hand's knuckle area. Both times the injured areas were appropriately cleaned and treated; vital signs and neuro checks were completed; and proper notifications were made. On 10/09/19 at 10:29 AM, an interview with Registered Nurse (RN#96) revealed at every morning meeting a post fall review from the day before is completed. If a fall is unwitnessed or if the resident hits their head, then a physical therapy referral is made for an evaluation and neuro checks are done for 3 days after the fall. Records showed an interdisciplinary team (IDT) meeting note dated 8/20/19, was held to discuss the fall occurring on 8/19/19. The note included the following Intervention: hey therapy (physical therapy referral), neuro-checks, skin treatment/first aid, provider eval with an order for [REDACTED]. Review of R#116's care plan, on 10/09/19 at 10:56 AM, revealed only one revision concerning the fall was made to the care plan after the 1st fall out of the wheelchair. The revision was made on 08/22/19. The revision stated, to have reacher at bedside. A reacher is a reaching extension tool used for grasping items in hard-to-reach places without having to bend over. An interview with RN#96, on 10/09/19 at 11:08 AM, revealed RN#96 confirmed the care plan was not revised appropriately. RN#96 said, The resident did not fall out of the bed, but both times out of his wheelchair, reaching for things on the ground. The care plan should not have limited the reacher to be only at bedside, so it would be available when or where he needed it. On 10/09/19 at 01:12 PM, an interview and review of records with Resident Care Management Director (RCMD#165) responsible for developing resident's MDS and care plans, revealed R#116 care plan was not revised as it should have been, to address the issue of the resident falling out of his wheel chair due to reaching for items on the ground. Also, the care plan was not revised with any new or different interventions when the resident fell out of the wheelchair the second time while reaching for items on the ground. 2. Resident (R#116) Behavioral needs Review of resident (R#116)'s recent annual minimum data set (MDS) with an assessment reference date (ARD) 09/06/19, on 10/08/19 at 03:53 PM, revealed the following. The resident's Brief Interview for Mental Status (BIMS) score is 3 indicating the resident has a severe cognitive impairment. The resident did not have any behaviors during the 7 day look back period. R#116 needs extensive assistance with all activities of daily living and has range of motion impairments on both sides of his upper and lower extremities. The resident has an indwelling catheter and is continent of bowels. Some pertinent [DIAGNOSES REDACTED]. The resident takes Antipsychotic medication daily and was admitted to the facility on [DATE]. Review of records showed an order for [REDACTED].#116 refused care. Review of the care plan revealed a care area receives antipsychotic medication [MEDICATION NAME] d/t refusal of care r/t [MEDICAL CONDITION]. The care plan did not reveal a care focus area concerning refusing care or any other interventions to address refusing care, such as encouraging, prompting, cueing, or redirecting. Review of the (MONTH) and (MONTH) 2019 medication administration records (MARs) revealed Observation: Antipsychotic Med: Observe for behavior: refusal of care & doc. #of episodes (and document number of episodes). Observe for side effects: (listed side effects) Document 'Y' if resident is free of side effects. 'N' if the resident is not free of side effects. If 'N' document SE (side effects)in the progress notes every shift. Neither month documented the resident refused care. The MAR indicated [REDACTED]. Observations made by Surveyor # and Surveyor # during the initial dining tour revealed R#116 eating his lunch with his face down in his plate using his mouth to eat out of his plate without the use of any eating utensils or his fingers. On 10/09/19 at 10: 44 AM, an interview with Registered Nurse (RN#96) revealed R#116 has behaviors and has a [DIAGNOSES REDACTED].#96 described the resident has verbal outburst; is easily agitated; and has unusual mannerisms like the way he eats with his mouth in his plate. When asked where staff monitors and documents these behaviors, RN#96 said on the MAR (medication administration record) with the [MEDICAL CONDITION] medication. RN#96 denied there was any other behavior monitoring sheet to track identified behaviors other than the MAR. On 10/09/19 at 12:53 PM resident was observed in dining room without participating in lunch. The resident stated he was going to wait until dinner and did not want lunch now. Nursing Assistant Mentor (NA#54) was monitoring the dining room. An interview with Nursing Assistant Mentor (NA#54), who helps train newly hired NAs, revealed she often observes R#116 using unusual eating habits at meals. NA#54 stated she has worked at the facility a few years prior to R#116 being admitted to the facility. NA#54 said since R#116 has been at the facility, she has often seen R#116 placing his face in his plate when eating, she said, He usually does. NA#54 stated, It's like, he likes to sleep in it. If anyone tries to correct him, he will go off. This surveyor asked if R#116 had ever fallen asleep in his food, NA#54 denied ever seeing him sleeping in his plate, but said, It just looks like it sometimes. When asked, How would a newly employeed NA know about his specific behaviors and how they should handle them? NA#54 said grinning, If they try to correct him, they will get an ear full. They should follow the Kardex, it comes from the care plan. This surveyor asked, Is his eating behavior and other behaviors addressed in the care plan? NA#54 replied, I would like to think so. It should be addressed in it. When asked what NAs are trained to do if the resident has an outburst or is agitated, NA#54 replied, They should redirect him and use a calming voice. They should just follow the care plan. On 10/09/19 at 01:12 PM, an interview and review of records with Resident Care Management Director (RCMD#165) responsible for developing MDSs and care plans, revealed R#116 care plan was not revised to monitor or address his unusual eating habit or different behaviors unique to R#116. Review of care plan revealed a focus area, (Resident's name) is verbally aggressive at times and will curse and yell. The 3 interventions noted in the care plan were Administer medications as ordered. Observe/document for side effects and effectiveness.; Give the resident as many choices as possible about care and activities.; and Psychiatric/Psychogeriatric consult as indicated. There was no guidance to staff on individualized specific strategies that R#116 responds to or works well for the resident. RCMD#165 agreed the care plan needed to be revised to include more individualized and person-centered strategies to address the resident's specific behaviors. b) Resident #94 During a record review, Resident #94's care plan noted the resident received total paranteral nutrition (TPN). TPN is an intravenous (IV) fluid that attempts to provide all the body's need for nutrition without using the gastrointestinal (GI) tract. Review of Residents #94's care plan found a focus/problem: [NAME] will self disconnect TPN from catheter. The goal associated with this problem: [NAME] will have fewer episodes of listed behaviors by review date. Interventions included: -- Allow choices within individual's decision making abilities. -- Anticipate and meet the resident's needs. Focus/problem: [NAME] has a potential fluid deficit r/t (related to) need for TPN. The goal associated with this problem: [NAME] will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. Interventions included: -- Ensure the resident has access to fluids of choice whenever possible. During an interview on 10/09/19 at 10:48 AM, Employee #165, Care Management Minimum Data Set (MDS) Director, confirmed the resident no longers receives TPN. Employee #165 stated that the care plan had not been updated since the TPN had been discontinued. On 10/09/19 at 11:06 AM, the findings were discussed with the Administrator, the Director of Nursing (DON), and the District Director of Clinical Services.",2020-09-01
152,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,684,E,0,1,RPKM11,"**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 ensure each resident received medication as physicians orders; which includes the administration of medication timely for five (5) out of thirty-five (35) sampled residents. This failed practice had the potential to affect more than a limited number of residents residing at the facility. Resident identifiers: #139, #182, #130, #37 and #432. Facility census: 182. Findings included: a) Resident #139 Medical record review for Resident #139, revealed he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident is unresponsive and requires a gastrostomy feeding tube for all nutritional needs and [MEDICAL CONDITION] in place secondary to [MEDICAL CONDITION]. Resident #139 is to receive nothing by mouth (po) secondary to dysphagia and aspiration. Further review of Resident #139's medical records found an order for [REDACTED]. Review of the Controlled Medication Utilization Record for 09/29/19 at 1:00 am through 10/01/19 at 5:00 pm, found Resident #139 received [MEDICATION NAME] 20 mg per 1ml; which equals 20 mgs by mouth (po) every hour. Resident #139 received fifty-one (51) doses of 20 mgs of [MEDICATION NAME] instead of the 4mgs and the resident received the [MEDICATION NAME] po instead of SL as ordered. Interview with attending physician on 10/09/19 at 5:00 pm revealed the [MEDICATION NAME] should be given SL not po and the dosage should be 20mg per 1 ml - give 0.25 ml which equals 4 mg every hour as needed for pain. Clarification orders noted by the attending physician to give SL not po due to aspiration. Interview on 10/10/19 at 10:00 am with the Director of Nursing (DON), found the resident received the wrong dosage of [MEDICATION NAME] on the above dates. Additionally, she confirmed the [MEDICATION NAME] was to be given SL but was documented it was administered po. Review of Resident #139's medical record found an order for [REDACTED]. Order effective 08/15/19. Review of the August, (MONTH) and (MONTH) 2019, Medication Administration Record [REDACTED]. Interview with the DON on 10/10/19 at 10:00 am, confirmed the resident's blood pressure and heart rate was not taken and documented prior to the administration of the [MEDICATION NAME]. b) Resident #182 Review of Resident #182's medical record found an order for [REDACTED]. Order effective 06/17/19. Review of the June, July, and (MONTH) 2019, Medication Administration Record [REDACTED]. Interview with the DON on 10/10/19 at 10:00 am, confirmed the resident's heart rate was not taken and documented prior to the administration of the [MEDICATION NAME]. c) Resident #130 During a review of the Medical Administration Record (MAR), it revealed, was ordered: [MEDICATION NAME] Powder 0 Units/Grams, to be applied every shift to the groin. (This is an antibiotic which is used for both fungal and/or yeast infection). It is recommended to be given two (2) three (3) times a day and given at the same time daily. The facility nurses are scheduled from 7:00 AM, to 7:00 PM, and 7:00 PM, to 7:00 AM. Therefore, making the medication due every 12 hours. Below are the times it was administrated: On 10/01/19 due at 7:00 AM- time given-1:58 PM. The next dose due 7:00 PM-time given- 7:25 PM. Making the time between the first dose and the second dose, five (5) hours and 25 minutes. On 10/05/19 due at 7:00 AM- time given-5:10 PM, the second dose due at 7:00 PM-time given- 8:19 PM. Making the time between the first and second dose, three (3) hours and 9 minutes. On 10/06/19 due at 7:00 AM-time given-5:58 PM, the second dose due at 7:00 PM-time given-8:20 PM. Making the time between the first dose and second dose, one (1) hour and 22 minutes. During an interview on 10/09/19 at 12:30 PM, Director of Nursing about late medication administration and being given too close together to the next dose. She said, it can be given anytime during their shift. She was asked if she thought that one (1) hour to five (5) hour was to close together between doses was beneficial? She said, that she would look into it. d) Resident #37 During review of the facility Medication Administration Record [REDACTED] On 10/01/19 the following medications were scheduled to be administrated at 9:00 AM and was documented as given at 11:07 AM. One (1) hour and seven (7) minutes beyond the allotted time: -[MEDICATION NAME] 40 milligrams (mg) once a day (is a diuretic to treat [MEDICAL CONDITION] for congested heart failure) -[MEDICATION NAME] Bisulfate 75 mg once daily (for congested heart failure). -Protein Liquid 30cc twice daily (for wound healing) -[MEDICATION NAME] 25 mg once daily (for hypertension). -Magnesium Oxide 400 mg once daily (supplement) -[MEDICATION NAME] XR 75 mg once daily (for mood disorder). -Bactrim DS 800-160 mg, twice a day (for acute hematogenous osteo[DIAGNOSES REDACTED]-bone infection-) -Acidophilus one (1) capsule twice a day (antibiotic) -[MEDICATION NAME] 325 (65 FE) once a day (for [MEDICAL CONDITION]) On 10/01/19 the following medications were scheduled to be administrated at 9:00 PM, and was documented as given at 11:12 PM, resulting in the medications being given one (1) hour and 17 minutes too late: -Bactrim DS 800/160 mg twice a day (Antibiotic) -Acidophilus twice a day (antibiotic) -[MEDICATION NAME] Solution Pen-injector 15 units at bedtime (used to control diabetes) On 10/02/19 Humalog five (5) units (for treatment of [REDACTED]. The next dose was scheduled for at 12:00 PM, and was documented as being administrated at 1:22 PM, this resulted in instead of of the administration time having four (4) hours between the two (2) scheduled doses, it was only -one (1) hour and 17 minutes- between them. Resident #37's glucose levels on this day were as follows: -6:30 AM, 148 -11:30 AM, 270 -4:30 PM, 94 On 10/02/19 the following medications were scheduled to be administrated at 9:00 AM and was documented as given at 12:05 AM. Two (2) hour and five (5) minutes late. -[MEDICATION NAME] 40 milligrams (mg) once a day (is a diuretic to treat [MEDICAL CONDITION] for congested heart failure) -[MEDICATION NAME] Bisulfate 75 mg once daily (for congested heart failure). -Protein Liquid 30cc twice daily (for wound healing) -[MEDICATION NAME] 25 mg once daily (for hypertension). -Magnesium Oxide 400 mg once daily (supplement) -[MEDICATION NAME] XR 75 mg once daily (for mood disorder). -Bactrim DS 800-160 mg, twice a day (for acute hematogenous osteo[DIAGNOSES REDACTED]-bone infection-) -Acidophilus one (1) capsule twice a day (antibiotic) -[MEDICATION NAME] 325 (65 FE) once a day (for [MEDICAL CONDITION]) On 10/02/19 the following medications were scheduled ti be administrated at 5:00 PM, and was documented as given at 8:36 PM, meaning it was received three (3) hour and 36 minutes late. -Tigecycline 50 mg intravenously two times a day, (for an acute hematogenous osteo[DIAGNOSES REDACTED]). On 10/02/19 the following medications were scheduled ti be administrated at 9:00 PM, and was documented as given at 11:43 PM, meaning it was received one (1) hour and 46 minutes late. -Bactrim DS 800/160 mg twice a day (Antibiotic) -Acidophilus twice a day (antibiotic) -[MEDICATION NAME] Solution Pen-injector 15 units at bedtime (used to control diabetes). On 10/05/19, Humalog five (5) units (for treatment of [REDACTED]. On 10/06/19 the following medications were scheduled to be administrated at 9:00 AM and was documented as given at 11:56 AM. one (1) hour and 56 minutes late. -[MEDICATION NAME] 40 milligrams (mg) once a day (is a diuretic to treat [MEDICAL CONDITION] for congested heart failure) -[MEDICATION NAME] Bisulfate 75 mg once daily (for congested heart failure). -Protein Liquid 30cc twice daily (for wound healing) -[MEDICATION NAME] 25 mg once daily (for hypertension). -Magnesium Oxide 400 mg once daily (supplement) -[MEDICATION NAME] XR 75 mg once daily (for mood disorder). -Bactrim DS 800-160 mg, twice a day (for acute hematogenous osteo[DIAGNOSES REDACTED]-bone infection-) -Acidophilus one (1) capsule twice a day (antibiotic) -[MEDICATION NAME] 325 (65 FE) once a day (for [MEDICAL CONDITION]) During an interview on 10/09/19 at 12:30 PM, Director of Nursing (DoN), was informed about late medication administration and the insulin being given too close. She said, I know it's not right, but I believe the nurses did given the medication on time, but did not document the time until later. She agreed that the nurses can manually enter a time given, however the electronic system records the actual time it was documented, and that time cannot be altered. e) Resident #432 During an interview on 10/07/19 at 11:21 AM, Resident #432 stated, she had to wait eight (8) hours on her first night here for pain medications. She went on to say, waits more than an hour every time she asks for her pain medication. Resident # 432 had knee surgery on 10/01/19 and was admitted to the facility on [DATE]. She was tearful during the interview, and she said, she had to stop her physical therapy just now, because she was in so much pain. The Physical Therapist Assistant #202 was in Resident #432's room at the beginning of the interview. He told her to let the physical therapy department know when she gets her pain under control, and they will try again. She stated, that she was supposed to get the pain medications before she goes to physical therapy. On this day that Resident #432 was in pain she received [MEDICATION NAME] 10-325 mg at 11:12AM. Her last dose was on 10/06/19 at 2:10 PM, which shows she did not receive any pain medication for 21 hours. During review of the facility Medication Administration Record [REDACTED]. On 10/04/19 Resident #432 was ordered [MEDICATION NAME] 10-325 mg every four (4) hours as needed for pain. Licensed Practical Nurse (LPN) #43 recorded the administration time this at 8:25 PM, however the electronic audit record shows this medication was administrated on 10/05/19 at 12:06 AM. Which is a four-hour (4) difference in time. On 10/04/19 the following medications were scheduled for 9:00 PM, and the recorded time documented was 11:46 PM. This was one (1) hour and 46 minutes late: -[MEDICATION NAME] 150 mg (for [MEDICAL CONDITION]) -[MEDICATION NAME] Sodium 100 mg (for constipation) -Requip 3 mg (for restless leg syndrome) The following medications were scheduled for 9:00 PM, and the recorded time documented was 12:13 AM. This was two (2) hours and 13 minutes late. -[MEDICATION NAME] 5 mg (for diabetes) - [MEDICATION NAME] 40 mg ([MEDICAL CONDITION]) On 10/06/19 [MEDICATION NAME] 10-325 mg LPN #167 put 2:00 AM, as the time administration, the electronic audit record shows this medication was administrated at 8:24 AM. This was a seven (7) hour and 24-minute difference in time. This same medication was recorded as being administrated at 8:27 AM. Which was three (3) minutes after the last time this medication was given. [MEDICATION NAME] 10-325 mg (is an opioid pain medication) and is commended to not to be given in a higher dose than 10-325 mg. On 10/06/19 [MEDICATION NAME] 10-325 mg, LPN #37 documented she administrated this medication at 10:09 AM, the electronic audit records show this medication was documented as given at 2:09 PM and again at 2:10 PM. On 10/07/19 the following medication were scheduled administration time was 9:00 AM and was documented on the electronic audit record shows the medication were administrated at 12:42 PM. This resulted in the medications being two (2) hours and 42 minutes late. -[MEDICATION NAME] Solution Pen-injector 1.8 milliliters daily (for diabetic control of blood glucose) -[MEDICATION NAME] Sodium injection 40 mg (use following a surgical joint replacement to prevent blood clots) -[MEDICATION NAME] 50 mg daily (treatment for [REDACTED].>-[MEDICATION NAME] 5 mg twice daily (treatment for [REDACTED].>-[MEDICATION NAME] 150 mg twice daily (treatment for [REDACTED].>-Duloxetine 30 mg daily (treatment for [REDACTED].>-[MEDICATION NAME] 300 mg daily (treatment for [REDACTED].>-[MEDICATION NAME] 40 mg twice daily (for [MEDICAL CONDITION]) -[MEDICATION NAME] XL 25 mg daily (for hypertension) -Aspirin 325 mg daily (used after joint replacement) On 10/07/19 the following medication were scheduled administration time was 1:00 PM and was documented on the electronic audit record shows the medication were administrated at 3:19 PM. This resulted in the the medications being two (2) hours and 19 minutes late, by LPN #50: -[MEDICATION NAME] 40 mg (for hypertension) During an interview on 10/09/19 at 12:30 PM, Director of Nursing (DoN), was informed about late medication administration and the insulin being given too close. She said, I know it's not right, but I believe the nurses did given the medication on time but did not document the time until later. She agreed that the nurses can manually enter a time given, however the electronic system records the actual time it was documented, and that time cannot be altered.",2020-09-01
153,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,689,D,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide an environment free from accident hazards over which the facility had control. This was true for 1 of 5 residents reviewed for care area of accidents. This practice had the potential to affect a limited number of residents. Resident identifiers: R#116. Facility census: 181 Findings included: a) Resident #116 Review of resident (R#116)'s recent annual minimum data set (MDS) with an assessment reference date (ARD) 09/06/19, on 10/08/19 at 03:53 PM, revealed the following. The resident's Brief Interview for Mental Status (BIMS) score is 3 indicating the resident has a severe cognitive impairment. R#116 needs extensive assistance with all activities of daily living and has range of motion impairments on both sides of his upper and lower extremities. The resident has an indwelling catheter and is continent of bowels. Some pertinent [DIAGNOSES REDACTED]. The resident takes Antipsychotic medication daily. The resident has history of falls and currently participates in occupational therapy services. Review of records, on 10/08/19 at 04:23 PM, revealed the resident had an unwitnessed fall in the courtyard on 08/19/19. The resident fell out of his wheelchair bending forward to retrieve an item off the ground. The resident suffered an abrasion above the right eye on 08/19/19. Approximately a month later, on 09/12/19, the resident again fell out of wheelchair in courtyard reaching forward to pick something up off the ground, causing an abrasion to the back of his left hand's knuckle area. On 10/09/19 at 10:29 AM, an interview with Registered Nurse (RN#96) revealed at every morning meeting a post fall review from the day before is completed. If a fall is unwitnessed or if the resident hits their head, then a physical therapy referral is made for an evaluation and neuro checks are done for 3 days after the fall. Records showed an interdisciplinary team (IDT) meeting note dated 8/20/19, was held to discuss the fall occurring on 8/19/19. The note included the following Intervention: hey therapy (physical therapy referral), neuro-checks, skin treatment/first aid, provider eval with an order for [REDACTED]. Review of records showed a revision was made to R#116's care plan after the first fall but no revisions were made the second time the resident had a similar fall. R#116's care plan, on 10/09/19 at 10:56 AM, revealed the facility's intervention was to provide the resident with a reacher at bedside. A reacher is a reaching extension tool used for grasping items in hard-to-reach places without having to bend over. This intervention would be helpful to the resident with picking up items without the resident stretching out and toppling forward, however the resident was not toppling forward out of his bed, but out of his wheelchair. There was no evidence the facility assessed or reevaluated the effectiveness of the intervention of a reacher bedside after the resident had the second similar fall. There was no evidence the facility monitored or encouraged the resident to use the reacher. An interview with RN#96, on 10/09/19 at 11:08 AM, revealed RN#96 confirmed there was no evidence the facility assessed or reevaluated the effectiveness of the intervention of a reacher bedside. RN#96 said, The resident did not fall out of the bed, but both times out of his wheelchair, reaching for things on the ground. RN#96 reviewed records and confirmed there was no evidence the facility monitored or encouraged the resident to use the reacher, nor were there any other different interventions put into place after the second fall.",2020-09-01
154,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,698,D,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Bsed on record review and staff interview, the facility failed to ensure the [MEDICAL TREATMENT] Communication Record post [MEDICAL TREATMENT] section was completed for Resident #151 each time he went to [MEDICAL TREATMENT]. The facility failed to follow up with the [MEDICAL TREATMENT] center regarding pre and post weights, and failed to follow the medication recommendations from the [MEDICAL TREATMENT] center. This practice had the potential to affect a limited number of residents. Resident identifiers: R#151. Facility census: 181 Findings included: a) Resident #151 Resident (R#151) was transferred and admitted to the facility on [DATE], after the resident had a failed kidney transplant. Some pertinent [DIAGNOSES REDACTED]. The resident was admitted to current [MEDICAL TREATMENT] services on 09/04/19. Interview with Licensed Practical Nurse (LPN#84), on 10/09/19 at 01:55 PM, revealed the facility maintains a communication record with the [MEDICAL TREATMENT] center in a [MEDICAL TREATMENT] communication book. The facility keeps forms in the book that requires pertinent information to be recorded by [MEDICAL TREATMENT] staff and facility nursing staff. Review of the resident's [MEDICAL TREATMENT] communications book with LPN#84 revealed the post [MEDICAL TREATMENT] section for R#151 was not completed by [MEDICAL TREATMENT] staff each time R#151 went to [MEDICAL TREATMENT]. The facility staff failed to follow up and obtain the pre and post weights from the [MEDICAL TREATMENT] center on 09/06/19, and post weights on 09/11/19. The facility staff failed to follow up or discontinue medications the [MEDICAL TREATMENT] center identified on 09/06/19 and requested the resident stop taking. ` The [MEDICAL TREATMENT] communication sheet dated 09/06/19 revealed no pre or post [MEDICAL TREATMENT] weights were recorded. In the 'Recommendation/Follow-up' section of the communication sheet dated 09/06/19 where orders from the [MEDICAL TREATMENT] center are written, the [MEDICAL TREATMENT] center specified Stop Calcium Acetate, Stop [MEDICATION NAME], and Please continue [MEDICATION NAME]. Review of records showed, since R#151's admission to the facility, the resident was not taking [MEDICATION NAME] or [MEDICATION NAME]. The resident was taking [MEDICATION NAME] suspension related to kidney transplant status, which is a [MEDICATION NAME] for organ rejection. The resident was taking Calcium Acetate 1334 mg daily and continued to take it until surveyor intervention. LPN#84 confirmed staff should have contacted the [MEDICAL TREATMENT] center and obtained weights, followed the [MEDICAL TREATMENT] center recommendations, and clarified the resident's medications. Review of orders revealed Calcium Acetate Capsule 667 mg (milligrams). Give 2 capsule by mouth with meals every Mon, Wed, Fri related to End Stage [MEDICAL CONDITION] (Time on [MEDICAL TREATMENT] days) 2 capsules to equal 1334 mg; and Calcium Acetate Capsule 667 mg. Give 2 capsule by mouth with meals every Tue, Thu, Sat, Sun related to End Stage [MEDICAL CONDITION] (Timed for non-[MEDICAL TREATMENT] days) 2 capsules to equal 1334 mg. Review of R#151's Medication Administration Record [REDACTED]. The resident received Calcium Acetate (a base binder) for thirty-three (33) more days after it should have been discontinued. On 10/10/19 at 11:53 AM, a phone interview with the [MEDICAL TREATMENT] Center Clinic Manager revealed R#151 was admitted to [MEDICAL TREATMENT] service on 09/04/19 and labs were taken at that time showing the resident's calcium was high and phosphorus level was low. Calcium and phosphorus are essential minerals found in the bone, blood and soft tissue of the body and have a role in numerous body functions. The [MEDICAL TREATMENT] Center Clinic Manager stated their doctor does not like to use a calcium base binder (binds to phosphorus to remove phosphorus from the body) and since the resident's phosphorus was already low. The [MEDICAL TREATMENT] Center Clinic Manager voiced concern that by R#151 continuing to take the binder it could make R#151's phosphorus levels even lower. The [MEDICAL TREATMENT] Center Clinic Manager said the facility had contacted them yesterday and notified them the resident had continued to receive the Calcium Acetate, so labs were drawn, and they were awaiting the results. (Surveyor was notified by the [MEDICAL TREATMENT] Center Clinic Manager the last lab results were within normal limits.)",2020-09-01
155,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,711,E,0,1,RPKM11,"**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 signed and dated all orders. This was random opportunity for discovery. This failed practice had the potential to affect more than a limited number of residents. Resident identifier: #94, #9, and #95. Facility census 182. Findings included: a) Resident #94 On 10/08/19 at 2:59 PM, during a review of the thinned medical record for a bed hold notification, the surveyor discovered several physician orders [REDACTED]. On 10/08/19 at 3:50 PM, Employee #73, Health Information Coordinator, confirmed that the physician orders [REDACTED].#73 was asked to copy all orders that were flagged. The following orders had not been signed by the physician: --03/21/19 16:02 - [MEDICATION NAME] HCI Tablet 20 MG Give 1 tablet by mouth every 8 hours for abdominal pain. discontinue --03/21/19 16:02 - [MEDICATION NAME] HCI Capsule 10 MG Give 1 capsule by mouth every 6 hours as needed for abdominal pain related to postsurgical malabsorption, not elsewhere classified --03/19/19 05:25 - Apply nourishing skin cream to bilateral lower extremities including feet, every shift for dry skin. discontinue --03/19/19 05:27 - Cleanse bilateral buttocks and coccyx with warm soapy water, rinse, pay dry, apply inzo barrier cream topically every shift for increased risk of skin breakdown and as needed. --03/19/19 05:27 - Cleanse bilateral buttocks, coccyx and sacrum with warm soapy water, rinse, pat dry, apply [MEDICATION NAME] cream topically as needed AND every shift for increased risk of skin breakdown. discontinue --03/19/19 05:28 - Cleanse wound to sacrum with warm soapy water, rinse, pat dry, apply inzo barrier cream topically. Monitor skin surrounding area and report abnormalities to provider. Document in nurses notes if indicated, as needed for wound healing and every shift for wound healing. --03/19/19 05:30 - Cleanse wound to sacrum with warm soapy water, rinse, pat dry, apply thin layer [MEDICATION NAME] paste topically. Monitor skin surrounding area and report abnormalities to provider. Document in nurses notes if indicated, as needed for wound healing and every shift for wound healing. --03/19/19 05:41 - Cleanse wound to sacrum with warm soapy water, rinse, pat dry, apply inzo barrier cream topically. Monitor skin surrounding area and report abnormalities to provider. Document in nurses notes if indicated, as needed for wound healing AND every shift for wound healing. discontinue --03/19/19 06:43 - ROHO cushion to wheelchair at all times, verify placement every shift for wound healing. --03/16/19 07:48 - BMP on Monday 3/18/19 one time only for hypertension until 03/18/2019 23:59 --03/17/19 17:33 - Send resident to CHH ER to replace PICC line d/t (due to) TPN use. one time only until 03/17/2019 23:59. --03/08/19 11:51 - Senna-S-Tablet 8.6-50 MG (Sennosides-[MEDICATION NAME] Sodium) Give 2 tablet by mouth every 24 hours as needed for constipation 2 tablets = 17.2 mg/100mg. Hold 03/08/19 11:51 --03/11/19 11:50 loose stool --02/28/19 16:13 - Sodium Chloride Flush Solution Use 50 ml/hr intravenously in the morning for BUN and Creatinine trending up related to postsurgical malabsorption, not elsewhere classified via central line - while TPN is not Scheduled to run (9am-9pm). --02/28/19 16:13 - Sodium Chloride Flush Solution Use 50 ml/hr intravenously in the morning for BUN and Creatinine trending up related to postsurgical malabsorption, not elsewhere classified via central line - while TPN is not Scheduled to run (9am-9pm). discontinue increased weight gain --02/28/19 16:04 - House Supplement three times a day sugar free health shakes - no straws. discontinue weight gain --02/22/19 14:58 - THERAPY: Occupational Therapy Evaluation and Treatment. discontinue Highest practical level met --02/25/19 08:00 - [MEDICATION NAME] Tablet 20 MG ([MEDICATION NAME]) Give 1 tablet by mouth two times a day related to essential (primary) hypertension; chronic combined systolic (congestive) and diastolic (congestive) heart failure. discontinue --02/25/19 13:23 - CBC Due to cough, BMP due to CKD, BNP due to [MEDICAL CONDITION] one time only until --02/26/2019 23:59 --02/25/19 13:36 - [MEDICATION NAME] Tablet 40 MG ([MEDICATION NAME]) Give 1 tablet by mouth one time a day related to localized [MEDICAL CONDITION]. discontinue. Increased dose --02/25/19 13:28 - [MEDICATION NAME] Tablet 40 MF ([MEDICATION NAME]) Give 1 tablet by mouth one time a day for localized [MEDICAL CONDITION]. --02/25/19 13:30 - [MEDICATION NAME] Tablet 20 MG ([MEDICATION NAME]) Give 1 tablet by mouth one time a day for localized [MEDICAL CONDITION]. --02/22/19 13:30 - TPN: Upon competition of infusion, discontinue and discard unused TPN and tubing. Change needleless connectors and flush line. RN to perform in the morning. --02/22/19 13:30 - TPN: Upon competition of infusion, discontinue and discard unused TPN and tubing. Change needleless connectors and flush line. RN to perform in the morning. discontinue. Clarification --02/22/19 13:26 - [MEDICATION NAME] Solution 10 % Use 1 liter intravenously as needed for if TPN not available or interrupted via central line - see detailed order under other --02/22/19 13:26 - [MEDICATION NAME] Solution 10 % Use 1 liter intravenously as needed for if TPN not available or interrupted via central line - see detailed order under other DISCONTINUE. Clarification. --02/22/19 13:2 - Infusion Set Miscellaneous (IV Sets - Tubing) 1 unit miscellaneous as needed for non-sterile, tubing disconnected, malfunction etc CHANGE 1.2 Micron filter tubing to infuse TPN. Ensure appropriate filter. Label with initials, date, and time. RN to perform AND 1 unit miscellaneous at bedtime for routine care / TPN infusion CHANGE 1.2 Micron filter tubing to infuse TON, Ensure appropriate filter. Label with initials, date, and time, RN to perform. --02/22/19 13:23 - Infusion Set Miscellaneous (IV Sets - Tubing) 1 unit miscellaneous as needed for non-sterile, tubing disconnected, malfunction etc CHANGE 1.2 Micron filter tubing to infuse TPN. Ensure appropriate filter. Label with initials, date, and time. RN to perform AND 1 unit miscellaneous at bedtime for routine care / TPN infusion CHANGE 1.2 Micron filter tubing to infuse TON, Ensure appropriate filter. Label with initials, date, and time, RN to perform. discontinue. Order clarification. --02/22/19 13:16 - Misc. Devices Miscellaneous 1 unit miscellaneous as needed for missing, damaged, etc change central line needleless connectors AND 1 unit miscellaneous in the morning for routine care change central line needleless connectors upon completion of TPN lipids daily. (RN to perform) AND 1 unit miscellaneous every day shift every Fri for routine care change central line needleless connectors with CVC dressing changes. --02/22/19 13:17 - Misc. Devices Miscellaneous 1 unit miscellaneous as needed for missing, damaged etc change needleless connectors AND 1 unit miscellaneous one time only for admission for 1 Day change needleless connectors with CVC dressing changes AND 1 unit miscellaneous in the morning for routine care change needleless connectors upon completion of TPN lipids daily. (RN to perform) AND 1 unit miscellaneous one time a day every Fri for routine change needleless connectors with CVC dressing changes. DISCONTINUE. Order clarification. --02/22/19 13:12 - Normal Saline Flush Solution 0.9% (Sodium Chloride Flush) Use 10 ml intravenously as needed for blood draws, etc flush central line AND Use 10 ml intravenously two times a day for routine care flush central line with 10 mls NSS upon starting and completion of TPN and lipid infusion. --02/22/19 13:12 - Normal Saline Flush Solution 0.9% (Sodium Chloride Flush) Use 10 ml intravenously as needed for blood draws, etc AN Use 10 ml intravenously two times a day for routine care flush with 10mls NSS upon starting and completion of TPN and lipid infusion. discontinue Order clarification. --02/22/19 07:00 - Ensure dressing to left chest tunneled IJ central line is clean dry and intact. Monitor site for increased [MEDICAL CONDITION], [DIAGNOSES REDACTED], bleeding, drainage. Document in nurses note and follow up with Provider as needed every shift. --02/22/19 13:09 - Ensure dressing to left tunneled IJ central line is clean dry and intact. Monitor for increased [MEDICAL CONDITION], [DIAGNOSES REDACTED], bleeding, and drainage. Notify provider. every shift (change dressing if C/D/I). discontinue. Order clarification. --02/22/19 13:06 - Sodium Chloride Flush Solution Use 75 ml/hr intravenously every shift for BUN and Creatinine trending up related to POST SURGICAL MALABSORPTION, NOT ELSEWHERE CLASSIFIED (K91.2) via central line-while TPN is not running. --02/22/19 13:07 - Sodium Chloride Flush Solution Use 75 ml/hr intravenously every shift for BUN and Creatinine trending up related to POST SURGICAL MALABSORPTION, NOT ELSEWHERE CLASSIFIED (K91.2) WHILE TPN IS NOT RUNNIN[NAME] DISCONTINUE. Clarification. On 10/09/19 at 8:22 AM, the findings were discussed with the Administrator and the Director of Nursing (DON) and no further information was provided. On 10/09/19 at 5:05 PM, the Medical Director stated that she cannot sign orders electronically, she still has to sign orders with a pen. b) Resident #9 On 10/08/19 at 2:59 PM, during a review of the thinned medical record for a bed hold notification, the surveyor discovered several physician orders [REDACTED]. On 10/08/19 at 3:50 PM, Employee #73, Health Information Coordinator, confirmed that the physician orders [REDACTED].#73 was asked to copy all orders that were flagged. The following orders had not been signed by the physician: --06/28/19 21:02 - Monitor raised area on forehead every shift for injury for fall --06/28/19 16:46 - Apply ice to raised area on forehead X (times) 20 min every 4 hours for injury from fall for 1 Day --06/28/19 16:46 - Neuro Checks in place for 72 hrs per facility protocol every shift for related to fall for 3 Days. --06/27/19 10:26 - Resident to move to room [ROOM NUMBER] B --06/27/19 13:30 - [MEDICATION NAME] Tablet 0.5 MG (LORazepram) Give 1 tablet by mouth one time a day related to generalized anxiety disorder --06/27/19 13:31 - [MEDICATION NAME] Tablet 0.5 MG (LORazepram) Give 1 tablet by mouth two times a day related to generalized anxiety disorder. discontinue. --06/27/19 13:31 - [MEDICATION NAME] Tablet 25 MG (QUEtiapine [MEDICATION NAME]) Give 2 tablet by mouth two times a day for refusal of care related to attention-deficit [MEDICAL CONDITION] disorder, predominately hyperactive type; adjustment disorder with mixed anxiety and depressed mood monitor and document outcome every shift . discontinue --06/27/19 13:33 - [MEDICATION NAME] Tablet 0.5 MG ([MEDICATION NAME]) Give 1 tablet by mouth one time a day related to generalized anxiety disorder 3 Days. --06/27/19 13:34 - [MEDICATION NAME] Tablet 0.5 MG ([MEDICATION NAME]) Give 1 tablet by mouth one time a day related to generalized anxiety disorder. discontinue. --06/27/19 13:32 - [MEDICATION NAME] Tablet 100 MG (QUEtiapine [MEDICATION NAME]) Give 1 tablet by mouth at bedtime for refusal of care related to attention-deficit [MEDICAL CONDITION] disorder, predominately hyperactive type Monitor and document outcomes. --06/27/19 13:50 - HSG CCD diet. HSF Mech Soft texture. Regular consistency, with ground meat and gravy supervision with all meals, double portions. --06/27/19 13:50 - HSG CCD diet, HSG Puree texture, Regular consistency, supervision with all meals, double portions. discontinue. Diet upgrade. --06/14/19 11:28 - Send resident to (local hospital) to be evaluated /treatment for [REDACTED]. --06/12/19 13:53 - [MEDICATION NAME] Solution 5 MG/ML ([MEDICATION NAME]) Inject 1 ml intramuscularly one time only for increased behaviors and combativeness for 1 Day --06/12/19 15:00 - Eternal Feed-Bolus: [MEDICATION NAME] HN - TWO CANS (474 cc) - via [DEVICE] in the morning related to DYSPHASI[NAME] DISCONTINUE. Per provider orders, resident to obtain nutrition through PO (by mouth) nutrition --06/12/19 15:00 - Apply barrier cream topically to bilateral buttocks, coccyx, and sacrum after each incontinent episode every shift for incont (incontinent) episodes, etc. --06/12/19 15:00 - Cleanse bilateral buttocks and coccyx with warm soapy water. Rinse and pat dry-apply Inzo barrier topically every shift for increased risk for skin breakdown AND as needed for increased risk for skin breakdown. discontinue --02/21/19 01:31 - [MEDICATION NAME] (Concentrate) Solution 20 MG/ML Give 0.25 ml sublingually every 4 hours as needed for pain must document at least 3 non-pharmalogical interventions and outcome of those interventions prior to administration --02/21/19 01:31 - [MEDICATION NAME] (Concentrate) Solution 20 MG/ML Give 0.25 ml sublingually every 4 hours as needed for pain must document at least 3 non-pharmalogical interventions and outcome of those interventions prior to administration. discontinue --02/21/19 12:46 - Monitor Vital Signs three times a day for 3 Days --02/11/19 14:35 - PLO [MEDICATION NAME] Gel (Premium Lecith Organogel Base) Apply to forearm topically two times a day related to unspecified dementia with behavioral disturbance 75mg/2ml-apply 2 ml. --02/11/19 14:38 - [MEDICATION NAME] XR Capsule Extended Release 24 Hours 74 MG ([MEDICATION NAME] HCI ER) Give 1 capsule via PE[DEVICE] one time a day for major [MEDICAL CONDITION]. discontinue. Changed route. --02/09/19 07:37 - Apply ice to Back of head for 15 minutes and then remove for 2 hours, repeat process as directed, every shift for unwitnessed fall for 1 Day. --02/09/19 06:21 - Cleanse skin tear to left elbow with NS, pat dry, apply TAO, non-adherent pad, wrap with [MEDICATION NAME], every day shift for 7 Days --02/09/19 06:21 - Neuro checks x 72 hours d/t (due to) fall every shift for 3 Days. --02/08/19 21:19 - Enteral: Mic-Key tube necessary to malnutrition and dysphasia-may not change at facility --02/08/19 21:19 - Enteral: PEG tube necessary to malnutrition and dysphasia - may not change at facility. discontinue. --02/07/19 18:02 - Enteral: Two-Cal HN at 55 ml/hr via PEG tube for 21 hours, 7 hours, on/1 hour off with 200 ml flushes every 3 hours-total K/cal 2310/24 hours every 8 hours. Turn tube feeding on AND every 8 hours Turn tube feeding off. DISCONTINUE. Changed to bolus feedings. --02/07/19 17:41 - Bolus: TWO CAL HN - TWO CANS - in the morning related to dysphasia, unspecified. --02/07/19 17:41 - Bolus: TWO CAL HN 237 cc at bedtime related to dysphasia, unspecified. --02/07/19 17:41 - Bolus: TWO CAL HN 237 cc in the afternoon related to dysphasia, unspecified. --02/07/19 17:41 - Bolus: TWO CAL HN 237 cc in the evening related to dysphasia, unspecified. --02/07/19 17:41 - FLUSHES: 250 cc free water flushes every 4 hours related to dysphasia, unspecified. --02/07/19 17:40 - [MEDICATION NAME] Tablet 5-325 MG ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet enterally every 6 hours for pain --02/07/19 17:40 - [MEDICATION NAME] Tablet 5-325 MG ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet via PE[DEVICE] every 8 hours for pain. discontinue Increased frequency d/t pain --01/27/19 02:33 - Neuro checks per facility policy for 72 hours. every shift for unattended fall for 3 Days. --01/27/19 02:41 - Cleanse abrasion to left elbow with NSS (normal saline solution), pat dry, and apply TAO. (MONTH) discontinue when healed. --01/27/19 02:43 - Cleanse abrasion to right cheek with NSS, pat dry, and apply TAO. (MONTH) discontinue when healed. --01/23/19 12:06 - Paste Base Paste Apply to bil buttocks, coccyx, sac topically every shift for incontinence acquired [MEDICAL CONDITION] for 14 Days Cleanse bilateral buttocks, coccyx, and sacrum with normal saline, apply magic buttpaste ([MEDICATION NAME] 1%, [MEDICATION NAME] 1:1:1 mix equal parts 180 GM AND Apply to bil buttocks, coccyx, and sacrum with normal saline, apply magic buttpaste ([MEDICATION NAME] 1%, [MEDICATION NAME] 1:1:1 mix equal parts 180 GM. --01/23/19 12:11 - Cleanse wound to sacrum with warm soapy water, rinse, pat dry, apply inzo barrier cream topically. Monitor skin surrounding area and report abnormalities to provider. Document in nurses notes if indicated, every shift for wound healing/increased risk for skin breakdown AND as needed for wound healing/increased risk for skin breakdown. DISCONTINUE. Wound rounds completed with Dr. Pinson and IDT. Paste base paste orders for bilateral buttocks, coccyx and sacrum d/t incontinence acquired [MEDICAL CONDITION]. Wound care will follow prn (as needed) and upon nurses request. --01/22/19 06:50 - Cleanse wound to sacrum with warm soapy water, rinse, pat dry, apply inzo barrier cream topically. Monitor skin surrounding area and report abnormalities to provider. Document in nurses notes if indicated, every shift for wound healing/increased risk for skin breakdown AND as needed for wound healing/increased for skin breakdown. --01/22/19 06:49 - Cleanse bilateral buttocks and coccyx with warm soapy water. Rinse and pat dry-apply Inzo barrier cream topically every shift for increased risk for skin breakdown AND as needed for increased risk for skin breakdown. --01/22/19 06:49 - Cleanse bilateral buttocks, coccyx and sacrum with warm soapy water. Rinse and pat dry-apply Inzo barrier cream topically every shift for increased risk for skin breakdown AND as needed for increased risk for skin breakdown. discontinue. --01/22/19 13:13 - [MEDICATION NAME] Tablet 0.5 MG ([MEDICATION NAME]) Give 1 tablet via PE[DEVICE] two times a day for increased agitation related to generalized anxiety disorder monitor and document outcome every shift. DISCONTINUE. Increasing frequency. --01/22/19 13:13 - [MEDICATION NAME] Tablet 0.5 MG ([MEDICATION NAME]) Give 1 tablet by mouth every 8 hours related to generalized anxiety disorder . --01/22/19 13:22 - HSG Puree diet HSG Puree texture, Nectar consistency, for pleasure food. --01/22/19 13:23 - HSG NPO (Nothing by Mouth) diet NPO (Nothing by Mouth) texture, NPO (Nothing by Mouth) consistency. discontinue. Hospice accepted resident has new diet order. --01/17/19 08:33 - Hospice Consult one time only for 1 Day. --01/16/19 11:53 - Flush PEG tube with 200cc water for hydration /to maintain patency every 3 hours. --01/15/19 15:21 - ADC: Do Not Resuscitate - Comfort - no IV fluids. If feeding tube has been removed by resident-leave out. --01/15/19 15:28 - ADC: Do Not Resuscitate - DNR - Limited interventions - R.N. may pronounce death-May have IV fluids for trial period-Feeding tube long-term. discontinue. Updated. --01/13/19 21:57 - [MEDICATION NAME] Cream 1 % Apply to abdomen topically two times a day for skin irritation apply to affected area around peg tube site. --01/12/19 0:39 - Apply sureprep to wound on left lateral malleolus. Monitor skin surrounding area and report abnormalities to provider. Document in nurses notes if indicated, every shift for wound healing AND as needed for wound healing. discontinue. Resolved. --01/12/19 07:23 - Consult: Occupational Therapy may evaluate and treat as indicated. --01/12/19 07:23 - Consult: Physical Therapy may evaluate and treat as indicated. --01/12/19 07:23 - Consult: Speech Therapy may evaluate and treat as indicated. --01/11/19 13:51 - [MEDICATION NAME] HCI Solution Reconstituted 750 MG Use 750 mg intravenously two times a day related to bacteremia. discontinue. VAMC discontinued. --01/11/19 13:51 - IV Catheter Kit 1 unit miscellaneous as needed for dressing not clean dry and intact Change PICC line dressing (Pharmacy please send central line dressing change trays) AND 1 unit miscellaneous every night shift every Mon, Fri for routine PICC care Change PICC line dressing (Pharmacy please send central line dressing change trays). discontinue. discontinued. --01/11/19 13:52 - Misc. Devices Miscellaneous 1 unit miscellaneous as needed for blood draw, malfunction, dressing changes, etc. Change needleless connectors (Pharmacy please send needleless connectors) AND 3 unit miscellaneous every night shift every Mon, Fri for routine PICC care Change needleless connectors (Pharmacy please send needleless connectors). discontinue. discontinue --01/11/19 13:52 - Kendall Luer Disinfectant Cap Miscellaneous (Parental Therapy Supplies) 1 unit miscellaneous as needed for missing, damaged etc change alcohol cap AND 1 unit miscellaneous in the morning for routine PICC care change alcohol cap after IV administration AND 3 unit miscellaneous every night shift every Mon, Fri for routine dressing changes change alcohol caps to all lumens. --01/06/19 17:05 -[MEDICATION NAME] HCI Solution Reconstituted 750 MG Use 750 mg intravenously two times a day related to bacteremia. --01/06/19 17:12 - [MEDICATION NAME] trough 30 minutes prior to 4th dose on 1/18/19 at 5 am. one time only for 1 Day. --01/05/19 18:03 - [MEDICATION NAME] Tablet 0.5 MG ([MEDICATION NAME]) Give 1 tablet by mouth one time only for increased agitation and refusal of care until 01/05/2019. --01/07/19 03:00 - Neuro checks every 30 min. x 4, every 1 hour x 4 hours x 24 hours, every 8 hours for the remaining 72 hours. discontinue. Order was for 72 hours only. --01/07/19 15:25 - left hip X-ray d/t fall/pain. discontinue. obtained. negative. --01/07/19 15:24 -Send to CHH ER/IR for replacement of PICC line d/t resident pulled out 1/4/19 at 8pm. discontinue. completed. --01/03/19 18:26 - XRAY OF BILATERAL HIPS, 2 VIEW STAT for FALLS/PAIN. --01/04/19 01:57 - Hold [MEDICATION NAME] until trough obtained one time only for 1 Day. --01/04/19 01:58 - [MEDICATION NAME] trough 30 minutes prior to 4th dose one time only for 1 Day. --01/04/19 05:58 - Cleanse skin tear to right forearm with normal saline, pat dry, cover with [MEDICATION NAME], wrap with kerflex. Monitor skin surrounding area and report abnormalities to provider. Document in nurses notes if indicated, as needed for skin tear for 10 Days AND every night shift for skin tear for 10 Days. --01/04/19 05:58 - Ensure dressing to right forearm is CDI (clean, dry, intact) every shift for ensure dressing is CDI for 10 Days. --01/02/19 17:30 - Apply sureprep to wound on left heel. Monitor skin surrounding area and report abnormalities to provider. Document in nurses notes if indicated, every shift for wound healing AND as needed for wound healing. discontinue. resolved. --01/02/19 11:03 - Low bed with bilateral floor mats at all times while in bed-verify position and placement every shift for history of falls. --01/02/19 11:04 - Floor mat to left side of bed AAT's (at all times) every shift for falls. --01/02/19 11:04 - Low Bed AAT's while in bed every shift for falls. --01/02/19 07:00 - Safety checks every shift for history of falls complete paper safety checks form. --01/02/19 11:11 - Safety checks every 30 minutes. --12/31/19 20:46 - Count number of steri strips and document. Leave steri strips in place until they fall off. every shift for skin tear. discontinue. new orders noted On 10/09/19 at 8:22 AM, the findings were discussed with the Administrator and the Director of Nursing (DON) with no further information provided. On 10/09/19 at 5:05 PM, the Medical Director stated that she cannot sign orders electronically, she still has to sign orders with a pen. c) Resident #95 On 10/08/19 at 2:59 PM, during a review of the thinned medical record for a bed hold notification, the surveyor discovered several physician orders [REDACTED]. On 10/08/19 at 3:50 PM, Employee #73, Health Information Coordinator, confirmed that the physician orders [REDACTED].#73 was asked to copy all orders that were flagged. The following orders had not been signed by the physician: --07/12/19 - Order Summary Report --09/21/19 08:12 - CBC, CMP q (every) 6 months d/t (due to)[MEDICAL CONDITION](hypertension) due Feb & Aug one time a day every 181 days(s) --09/21/19 08:12 - CBC, BMP q (every) 6 months d/t HTN. discontinue. Order clarification. --09/21/19 08:09 - vit d level one time only until 10/16/2019 23:59 --09/21/19 08:09 - vit d level one time only for 1 Day --09/21/19 08:08 - CMP, TSH, T4, FLP, annually due 07/2020 one time a day every 364 days(s) --09/21/19 08:08 - CMP, TSH, T4, FLP annually due 07/2020. DISCONTINUE. Order clarification. --09/19/19 20:51 - Acidophilus Capsule (Lactobacillus) Give 1 capsule by mouth every 12 hours for GI protection secondary to antibiotic use related to unspecified escherichia coli (E. coli) as the cause of diseases classified elsewhere unitary tract infection, site not specified. --09/19/19 20:51 - [MEDICATION NAME] Capsule 100 MG ([MEDICATION NAME] Monohyd Macro) Give 1 capsule by mouth two times a day related to unspecified escherichia coli (E. coli) as the cause of diseases classified elsewhere urinary tract infection, site not specified. for 7 Days. --09/19/19 20:52 - Nursing Progress Note every shift for antibiotic monitoring related to unspecified escherichia coli (E. coli) as the cause of diseases classified elsewhere urinary tract infection, site not specified. for 7 Days Also monitor closely for loose stools related to recent hx of [DIAGNOSES REDACTED] --09/19/19 20:55 - Vital Signs every 8 hours for antibiotic monitoring related to unspecified escherichia coli (E. coli) as the cause of diseases classified elsewhere urinary tract infection, site not specified for 7 Days. --09/19/19 20:55 - vitals q shift every 8 hours for 3 Days. --08/25/19 17:34 - Acidophilus Tablet (Lactobacillus) Give 1 tablet by mouth two times a day for ATB Therapy for 3 Days --08/25/19 17:34 - [MEDICATION NAME] Solution Reconstituted 1 GM (cefTRIAX Sodium) Inject 1 application intramuscularly at bedtime for UTI for 3 Days until finished. --08/25/19 17:38 - Temp Q shift while receiving ATB every shift for ATB Therapy for 3 Days. --07/16/19 11:52 - CMP in am one time only for 1 Day --07/16/19 11:52 - CMP in am one time only for 1 Day. discontinue --07/16/19 16:22 - Resident to be out of bed via hoyer lift for lunch daily every day shift for improved participation. On 10/09/19 at 8:22 AM, the findings were discussed with the Administrator and the Director of Nursing (DON) and no further information was provided. On 10/09/19 at 5:05 PM, the Medical Director stated that she cannot sign orders electronically, she still has to sign orders with a pen.",2020-09-01
156,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,726,E,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to have 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. Facility staff failed to ensure residents' advance directives contained in their Physician's Orders for Scope of Treatment (POST) forms were complete and/or accurately reflected in the physician's orders. Facility staff failed to ensure residents were free from chemical restraints. Facility staff failed to ensure physician's orders for medication parameters and medication dosages were followed. Facility staff failed to administer medications within the time period prescribed by the physician. Facility staff failed to provide [MEDICAL TREATMENT] services consistent with professional standards of practice. Facility staff failed to ensure residents were free from significant medication errors. Resident identifiers: 125, 139, 148, 9, 95, 108, 137, 161, 37, 130, 432, 182, 151. Facility census: 182. Findings included: a) Cross reference findings at F578 b) Cross reference findings at F605 c) Cross reference findings at F684 d) Cross reference findings at F698 e) Cross reference findings at F760",2020-09-01
157,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,756,E,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the consultant pharmacist recognized medications were administered without the required blood pressure and/or heart rates prior to the administration of [MEDICATION NAME] for two (2) random opportunities for discovery. This failed practice had the potential to affect a limited number of residents residing at the facility. Resident identifiers: #139 and #182. Facility census: 182. Findings included: a) Resident #139 Review of Resident #139's medical record found an order for [REDACTED]. Order effective 08/15/19. Review of the August, (MONTH) and (MONTH) 2019, Medication Administration Record [REDACTED]. Review of the monthly medication regimen reviews found the consultant pharmacist completed a medication review on 08/24/19, 09/09/19 and 10/03/19 with no recognition the [MEDICATION NAME] was being administered without the required heart rate and blood pressure obtained prior to the administration of the medication. Interview with the DON on 10/10/19 at 10:00 am, confirmed the resident's blood pressure and heart rate was not taken and documented prior to the administration of the [MEDICATION NAME] and the consultant pharmacist had not recognized the medication was being administered without the required blood pressure and heart rate. b) Resident #182 Review of Resident #182's medical record found an order for [REDACTED]. Order effective 06/17/19. Review of the June, July, and (MONTH) 2019, Medication Administration Record [REDACTED]. Review of the monthly medication regimen reviews found the consultant pharmacist completed a medication review on 06/21/19, 07/17/19, and 08/22/19, with no recognition the [MEDICATION NAME] was being administered without the required heart rate obtained prior to the administration of the medication. Interview with the DON on 10/10/19 at 10:00 am, confirmed the resident's heart rate was not taken and documented prior to the administration of the [MEDICATION NAME] and the consultant pharmacist had not recognized the medication was being administered without the required heart rate.",2020-09-01
158,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,757,E,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure each resident's drug regimen was free from unnecessary medications for three (3) random opportunities of discovery. This failed practice had the potential to affect more than a limited number of residents residing at the facility. Resident identifiers: #139, #182, and #151. Facility census: 182. Findings included: a) Resident #139 Review of Resident #139's medical record found an order for [REDACTED]. Order effective 08/15/19. Review of the August, (MONTH) and (MONTH) 2019, Medication Administration Record [REDACTED]. Interview with the DON on 10/10/19 at 10:00 am, confirmed the resident's blood pressure and heart rate was not taken and documented prior to the administration of the [MEDICATION NAME]. b) Resident #182 Review of Resident #182's medical record found an order for [REDACTED]. Order effective 06/17/19. Review of the June, July, and (MONTH) 2019, Medication Administration Record [REDACTED]. Interview with the DON on 10/10/19 at 10:00 am, confirmed the resident's heart rate was not taken and documented prior to the administration of the [MEDICATION NAME]. c) Resident (R#151) received Calcium Acetate after the [MEDICAL TREATMENT] Center wanted it to be discontinued. Resident (R#151) was transferred and admitted to the facility on [DATE], after the resident had a failed kidney transplant. Some pertinent [DIAGNOSES REDACTED]. The resident was admitted to current [MEDICAL TREATMENT] services on 09/04/19. Interview with Licensed Practical Nurse (LPN#84), on 10/09/19 at 01:55 PM, revealed the facility maintains a communication record with the [MEDICAL TREATMENT] center in a [MEDICAL TREATMENT] communication book. Review of the resident's [MEDICAL TREATMENT] communications book with LPN#84 revealed a [MEDICAL TREATMENT] center communication dated 09/06/19 for R#151 to stop taking Calcium Acetate. ` Review of orders revealed Calcium Acetate Capsule 667 mg (milligrams). Give 2 capsule by mouth with meals every Mon, Wed, Fri related to End Stage [MEDICAL CONDITION] (Time on [MEDICAL TREATMENT] days) 2 capsules to equal 1334 mg; and Calcium Acetate Capsule 667 mg. Give 2 capsule by mouth with meals every Tue, Thu, Sat, Sun related to End Stage [MEDICAL CONDITION] (Timed for non-[MEDICAL TREATMENT] days) 2 capsules to equal 1334 mg. Review of R#151's Medication Administration Record [REDACTED]. The resident received Calcium Acetate (a base binder) for thirty-three (33) more days after it should have been discontinued. On 10/10/19 at 11:53 AM, a phone interview with the [MEDICAL TREATMENT] Center Clinic Manager revealed R#151 was admitted to [MEDICAL TREATMENT] service on 09/04/19 and labs were taken at that time showing the resident's calcium was high and phosphorus level was low. Calcium and phosphorus are essential minerals found in the bone, blood and soft tissue of the body and have a role in numerous body functions. The [MEDICAL TREATMENT] Center Clinic Manager stated their doctor does not like to use a calcium base binder (binds to phosphorus to remove phosphorus from the body) and since the resident's phosphorus was already low. The [MEDICAL TREATMENT] Center Clinic Manager voiced concern that by R#151 continuing to take the binder it could make R#151's phosphorus levels even lower. The [MEDICAL TREATMENT] Center Clinic Manager said the facility had contacted them yesterday and notified them the resident had continued to receive the Calcium Acetate, so labs were drawn, and they were awaiting the results. (Surveyor was notified by the [MEDICAL TREATMENT] Center Clinic Manager the last lab results were within normal limits.)",2020-09-01
159,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,758,E,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents were free from unnecessary use of [MEDICAL CONDITION] medications. This was true for two (2) of five (5) reviewed for unnecessary medications. Resident identifiers: #161, and #9. Facility census: 182. Findings included: a) Resident #161 During a review of medical records for Resident #161 on 10/08/19 at 12:30 PM, revealed a statement on his Care Plan, it states, Resident #161 receives antipsychotic medication-- [MEDICATION NAME]-- for refusal of care/mood changes. This was initiated on 03/20/18. During an interview on 10/10/19 at 9:45 AM, Director of Nursing was asked about the care plan stating, that he was receiving this antipsychotic for refusal of care. She agreed, he should not be given a medication for refusal of care, and that it was his right to refuse showering/bathing. b) Resident #9 Review of the medical record revealed a current order, dated 08/05/19 for [MEDICATION NAME] tablet 200 mg at bedtime for refusal of care related to [MEDICAL CONDITION] disorder, recurrent, unspecified. A second order for [MEDICATION NAME] 100 mg, give 1 tablet in the morning for dementia related to dementia with Lewy Bodies was prescribed on 10/01/19. Review of the care plan found the resident refuses to wear his identification bracelet. The care plan also noted that the resident would refuse incontinent care. The care plan referenced the use of an anti-anxiety medication and said the resident refused care related to anxiety but the specific care refused was not documented. A review of Resident #9's [DIAGNOSES REDACTED]. On 10/10/19 at 11:26 AM, the findings were discussed with the Administrator and the Director of Nursing (DON). No further information was provided to indicated what type of care the resident refused, prior to the survey conclusion. There was no evidence provided to verify the resident refused any type of care that would have caused him harm. There was no evidence provided by the facility, prior to survey exit, of any behavioral interventions were explored other than medication. There was no evidence provided by the facility of non-pharmacological approaches attempted when the resident refused care that were directed toward understanding, preventing, relieving, and/or accommodating the resident refusals of care.",2020-09-01
160,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,760,D,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #139 was free from significant medication error. This failed practice had the potential to affect a limited number of residents residing at the facility. Resident identifier: #139. Facility census: 182. Findings included: a) Resident #139 Medical record review for Resident #139, revealed he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident is unresponsive and requires a gastrostomy feeding tube for all nutritional needs and [MEDICAL CONDITION] in place secondary to [MEDICAL CONDITION]. Resident #139 is to receive nothing by mouth (po) secondary to dysphagia and aspiration. Further review of Resident #139's medical records found an order for [REDACTED]. Review of the Controlled Medication Utilization Record for 09/29/19 at 1:00 am through 10/01/19 at 5:00 pm, found Resident #139 received [MEDICATION NAME] 20 mg per 1ml; which equals 20 mgs by mouth (po) every hour. Resident #139 received fifty-one (51) doses of 20mgs of [MEDICATION NAME] instead of the 4mgs and the resident received the [MEDICATION NAME] po instead of SL as ordered. Interview with attending physician on 10/09/19 at 5:00 pm revealed the [MEDICATION NAME] should be given SL not po and the dosage should be 20mg per 1 ml - give 0.25 ml which equals 4 mg every hour as needed for pain. Clarification orders was noted by the attending physician to give SL not po due to aspiration. Interview on 10/10/19 at 10:00 am with the Director of Nursing (DON), found the resident received the wrong dosage of [MEDICATION NAME] on the above dates. Additionally, she confirmed the [MEDICATION NAME] was to be given SL but was documented it was administered po.",2020-09-01
161,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,804,E,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on confidential resident and family interviews, observation, record review, and staff interview the facility failed to provide food to residents that was palatable and attractive. This deficient practice was found during a random opportunity for discovery and affected more than an isolated number of residents. Facility census: 182. Findings included: a) Test Tray On 10/09/19 at 9:18 AM a regular diet test tray was requested for that day's lunch time meal from the facility's Dietary Manager (DM). On 10/09/19 at 11:44 AM the test tray was received and examined by surveyors. The food on the test tray was unattractive. The tray included a watery bowl of discolored tomato and onion slices. The tomato slices were dark and dull. The egg salad sandwich on the tray was so soggy that the buns could not be separated from the egg salad between them. A small bowl on the tray contained a mixture of pineapple chunks and marshmallows. The contents of the bowl were watery, and the marshmallows were actively disintegrating in the excess moisture and turning to mush. The facility's Administrator was advised of the above findings on 10/10/19 at 9:14 AM. No further information was provided prior to exit. b) Confidential Resident #A (CR #A) During the survey, in a interview the CR #A described the facility food as so-so and mediocre. c) Confidential Resident #B (CR #B) During the initial interview the CR #B stated, Most of the time the food around here is cold by the time you get it and not fit to eat. When asked if the foods that were supposed to be served hot was not hot but cold, the resident confirmed and said, That's exactly what I mean. How would you like to eat cold mashed potatoes and gravy? It's disgusting. d) Confidential Resident #C (CR #C) CR #C said, the food is always bad. CR #C stated they do not order pizza or fish but, they still serve it to them. CR #C stated one evening they were not served dinner, then they served fish and then they asked for a grilled cheese. CR #C said the grilled cheese was never provided. e) Confidential Resident #D (CR #D) CR #D said the food is delivered cold, over cooked, has a lot of water in it, and with no seasoning. f) Confidential Resident #E (CR #E) CR #E said, the food is cold, and they are just tired of talking to them about it. They call it the food committee, but nothing changes. The food is over cooked to mush and no seasoning, so it tastes awful. g) Confidential Resident #F (CR #F) CR #F said, the food is[***]y, it's cold just taste bad, and looks bad. CR #F said they and the roommate order out three or four time a week. h) Confidential Resident #G (CR #G) CR #G said the food is cold. CR #G said they are allergic to peas, but they still serve it to them, plus it is totally over cooked and tasted bad. i) Confidential Resident #H (CR #H) CR #H said the food is cold and does not taste good. j) Confidential Resident #I (CR #I) CR #I said the food is cold never hot. The food has not been hot when it should have been. k) Confidential Resident #J (CR #J) During a confidential interview, CI #J stated the food is not at a temperature that they like. The food is not hot when it arrives in the resident's room. The food does not taste good. CI #J notes that salt cannot always be used, but there are other ways to season the food. The food does not have an appealing taste or the vegetables are not cooked properly. The vegetables are overcooked, soggy, mushy, and lack flavor. Also, according to CI #J, the trays do not get served on the unit(s) timely. There are many times that CI #J has had to wait 20 or more extra minutes for a tray to be delivered. On 10/10/19 at 9:14 AM, the findings regarding food palatability, appearance, watery side dishes, and desert variety was discussed with the Administrator. l) Confidential Resident #K (CR #K) During a confidential interview, CI #K stated the food does not taste good. Also, CI #K stated that the food is not hot when it is delivered to his / her room. On 10/10/19 at 9:14 AM, the findings regarding food palatability, appearance, watery side dishes, and desert variety was discussed with the Administrator. m) Confidential Resident #L (CR #L) During a confidential interview, CI #L stated the food is not at a temperature that he / she likes. The food is not hot when it arrives in the resident's room. The food does not taste good. The food is not seasoned and a lot of time the vegetables are soggy and mushy. CI #L states that he / she orders out several times a week due to the quality of the food at the facility. On 10/10/19 at 9:14 AM, the findings regarding food palatability, appearance, watery side dishes, and desert variety was discussed with the Administrator. n) Confidential Resident #M (CR #M) During a confidential interview, CI #M stated some days the food is not as hot as it should be. The food tasted ok, but could use more seasoning. On 10/10/19 at 9:14 AM, the findings regarding food palatability, appearance, watery side dishes, and desert variety was discussed with the Administrator. o) Confidential Resident #N (CR #N) During a confidential interview, CI #N stated that the food sometimes is not hot but it is getting better. The food is not seasoned and tastes bland. CI #N stated that he / she orders from Door Dash due to the food quality at the facility. On 10/10/19 at 9:14 AM, the findings regarding food palatability, appearance, watery side dishes, and desert variety was discussed with the Administrator. p) Resident Council A resident council meeting was held on 10/08/19 at 2:30 PM. Residents stated that there was too much water in food. Sometimes there about an inch of water in the bowl that side dishes were served in. Residents state that trays come out late, especially in the evenings. A review of resident council minutes showed the following: -- 8/27/19 - food not good cold and late -- 9/4/10 - facility conducting a food preference audit on every resident. -- 9/11/19 - no concerns listed. -- 9/26/19 - no issues listed for food. On 10/09.19, the Administrator provided copies of the Performance Improvement Project (PIP) regarding dietary concerns. On 10/09/19 at 3:20 PM, the District Director of Clinical Services reviewed the PIP provided by the Administrator. The PIP for the dietary department began on 08/22/19. The facility has added to the focus areas. The facility has added areas to the section What will you implement based on the Root Cause? -- Weekly Food Committee meeting in addition to Monthly meeting -- Customer Meal Satisfaction Survey -- Call back audit forms -- Dietary to meet with new admissions within 72 hours to discuss preferences -- 100% review of food preferences On 10/10/19 at 9:14 AM, the findings regarding food palatability, appearance, watery side dishes, and desert variety were discussed with the Administrator. q) Staff Interview On 10/09/19 at 9:45 AM, Administrator and Director of Nursing was asked what they have done to address the problems with the food. Administrator said, they have been having weekly meeting with the Residents, to talk about the food. They were asked what changes have been made. They had no response. They both agreed, that the Residents were still not happy about the food. They were both informed, the facility would get a citation about the appearance of the food. It was reported to them that the test tray was not appealing at all. Director of Nursing asked, if a detailed description would be in the findings about the test tray. She was informed that there would be a description of the test tray.",2020-09-01
162,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,812,E,0,1,RPKM11,"Based on observation, record review, and staff interview, the facility failed to maintain the kitchen and beverages distributed from the kitchen in a safe and sanitary manner. 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: 182. Findings included: a) Kitchen An initial tour of the facility's kitchen began on 10/07/19 at 10:53 AM. At 10:56 AM a square plastic container of lettuce in the reach-in cooler was found to have a use by date of 10/06/19. Also at 10:56 AM the reach-in cooler near the hand washing sink was found to have no temperature log. At 10:57 AM the facility's Dietary Manager (DM) confirmed that the lettuce had a use by date of 10/06/19. The DM then examined the lettuce closely and stated that it was still good. When asked for the facility's policy on what to do with a product that had passed its best by date, the facility's DM became silent and removed the lettuce from the cooler. At 10:58 AM the facility's DM confirmed there was no temperature log for the above-mentioned reach-in cooler. At 11:00 AM the dish machine temperature log was found to be blank on the following dates and times of the day during the month of (MONTH) 2019: breakfast, lunch, and dinner on 10/04/19, lunch and dinner on 10/05/19, and lunch and dinner on 10/06/19. Additionally, there was a large amount of scale running down the front of the machine. At 11:03 AM the facility's DM confirmed that the dish machine temperature log had not been filled out as it should have been. At 11:07 AM the facility's DM said that the large amount of scale running down the front of the dish machine was a constant problem. At 11:13 AM a 50 ounce can of chicken noodle soup with a large creased dent at the top seam was found in the dry storage area with food for resident service. At 11:14 AM the facility's DM confirmed that this severely damaged can should not have been in regular stock and then moved it to the damaged stock area of the dry storage room. The facility's Administrator was informed of the above findings on 10/07/19 at 2:44 PM. No further information was provided prior to exit. b) Third Floor On 10/07/19 at 12:20 PM a cart containing four (4) beverage pitchers to be used for lunch service was observed on the third floor of the facility. The pitchers were not labeled with dates. On 10/07/19 at 12:35 PM Dietary Employee (DE) #125 arrived on the third floor and examined the pitchers. DE #125 stated that there should have been dates on the pitchers. The above findings were discussed with the facility's Administrator on 10/07/19 at 2:44 PM. No further information was provided prior to exit.",2020-09-01
163,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,842,E,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure medical records were complete and accurate for 1 of 35 residents in the survey sample. The physician's orders [REDACTED].#19 did not specify the specific supplement. Resident identifier: #19. Facility census: 182. a) Resident #19 Resident #19 had an order written [REDACTED]. The specific supplement was not identified in additional directives. Resident #19's Medication Administration Record [REDACTED]. During an interview on 10/10/19 at 8:28 AM, Licensed Practical Nurse (LPN) #185 stated she was pretty sure Resident #19 was receiving Juven as the commercial supplement. During an interview on 10/10/19 at 8:40 AM, the Director of Nursing (DoN) was informed the physician's orders [REDACTED].#19 did not specify the specific supplement. The DoN had no further information regarding the matter. No further information was provided through the completion of the survey.",2020-09-01
164,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,867,E,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies. The facility had identified a deficient practice in the care area of advance directives, using medications as a chemical restaint for residents that refused care, failing to ensure all residents received medications that met the professional standard of practice, failing to ensure all orders were signed and dated by the physician, and failing to provide food that was palatable, attractive, to fit the needs of the residents, and their preferences. Has the potential to affect more than an isolated number of residents. Facility census 182. Findings included: a) Cross reference findings at F578 b) Cross reference findings at F605 c) Cross reference findings at F684 d) Cross reference findings at F711 e) Cross reference findings at F804 f) Interviews 1. During an interview on 10/10/19 at 11:52 AM, Director of Nursing (DoN) said, they did had audit in (MONTH) of 2019, and found no problems at that time. 2. Discussed the issues with the Post Forms with team and it was determined that the Post Forms was that was found to be incorrect the Post did not match the physician's orders [REDACTED]. Two (2) of the Post Forms were dated before the audit. 3. During an interview on 10/10/19 at 12:00 PM, Director of Nursing was asked about the orders not being signed and dated by the attending physician. DoN stated, that the physician was in transition for starting a new program for signing orders. 4. During an interview on 10/10/19 at 12:10 PM, DoN was asked the nurses not following perimeter on medication administration. DoN stated, that they were aware of the perimeters not being followed and did a Performance Improvement Procedure (PIP) in the Quality Assurance and Preformance Improvement (QAPI) meeting. She went on to say, they found the nurses had trouble using the sliding/scale (S/S) insulin, so they revised s/s to simplify the sliding scale, and worked with the pharmacist as to what Blood Pressure (B/P) medications have to have perimeters. So they stopped a lot of perimeters for these medication because they had been on the same medication for a long time and were stable. These problems are still problem madic, and that is on going during this survey. 5. On 10/10/19 at12:46 PM, DoN was asked about the post forms and the on going perimeters not being followed. She said, the pharmacist is monitoring monthly and the facility does audits quarterly. She agrees it needs to be monitored more often.",2020-09-01
170,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2019-07-10,656,D,0,1,5N8D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record reviews and staff interviews, the facility failed to develop a person-centered comprehensive care plan for two (2) of twenty one (21) care plans reviewed during the Long Term Care Survey Process (LTCSP). The care plan for R2 was not developed to address her end-of-life wishes and the care plan for R1 did not address the use of an arm sling. Resident identifiers: R1 and R2. Facility census: 53. Findings included: a) R2 During a medical record review on 07/10/19 revealed the care plan had not been developed to reflect R2's wishes for her end-of-life care. In an interview on 07/10/`19 at 9:35 AM with the Nursing Home Administrator verified, the care plan did not address the end-of-life wishes for R2. b) R1 During an interview and observation on 07/08/19 at 12:30 PM, R1 reported she was wearing an arm sling because she had broken her arm and dislocated her shoulder during a stay at another facility. Random observations during the survey revealed R #1's continued use of the right arm sling. Review of the medical record on 07/09/19, revealed an orthopedic note dated 07/18/18 with a [DIAGNOSES REDACTED]. The treatment included a right arm sling. The Occupational Therapy Discharge Note dated 07/30/2018 to 09/25/18, states under the section titled Equipment issued .pt (patient) continues to wear sling per her preference. The current care plan with a revision date of 07/09/19, is silent in regards to R1's continued use of the right arm sling. During an interview on 07/09/19 at 11:00 AM, Licensed Practical Nurse (LPN) #39 confirmed R1's care plan does not identify the arm fracture or address the sling she continues to wear for comfort.",2020-09-01
171,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2019-07-10,657,D,0,1,5N8D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the comprehensive care plan had been revised to reflect the discontinued use of a diabetic medication for R45. This was found to be true for one (1) of twenty one (21) care plans reviewed during the Long Term Care Survey Process (LTCSP). Resident identifier: R45 Facility census: 53. Findings included: a) R45 During a medical record review on 07/09/19 revealed the care plan for R2 had not been revised to reflect the discontinuation of the diabetic medication [MEDICATION NAME]. In an interview on 07/09/19 at 2:11 PM with the Director of Nursing, verified the care plan for R45 had not been revised to indicate the diabetic medication [MEDICATION NAME] had been discontinued on 03/06/19.",2020-09-01
172,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2019-07-10,684,D,0,1,5N8D11,"Based on observation, medical record review and staff interview, the facility failed to ensure R52 received treatment and care in accordance with professional standards of practice. During a random observation it was discovered the oxygen concentrator was delivering air flow to R52 at a rate of four (4) liters and not the prescribed two (2)-three (3) liters. This was true for one (1) of two (2) residents reviewed for Respiratory Care Services during the Long Term Care Survey Process (LTCSP). Resident identifier: R52. Facility census: 53. Findings included: a) R52 During an observation on 07/09/19 at 3:50 PM for R52, it was discovered the oxygen concentrator was delivering air flow to R52 at a rate of four (4) liters and not the ordered 2-3 liters via nasal cannula for shortness of breath. In an interview on 07/09/19 at 3:55 PM with E60 Licensed Practical Nurse (LPN) verified the oxygen concentrator for R52 was providing an air flow of four (4) liters and not the ordered two (2)-three (3) liters.",2020-09-01
173,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2019-07-10,689,D,0,1,5N8D11,"Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which the facility had control. A bottle of shampoo/body wash was accessible to residents in the unsecured community bathroom. This practice had the potential to affect more than a limited number of residents. Facility census: 53. Findings include:d a) Observations During initial tour observation of the middle of the facility hallway by activities room on 07/08/19 at 10:35 AM, discovered the community bathroom door open and unlocked. An eye wash station is located inside the bathroom and a 12 ounce bottle of Soothe and Cool Shampoo and Body Wash was found sitting in the basin of the eye wash station. The label stated, External use only. Avoid contact with eyes. b) Interview Immediately following the observation, Employee #69 walked into the open door of the bathroom and removed the bottle of the shampoo/body wash from the basin of the eye wash station. Upon inquiry she stated, No this bottle does not belong in the bath area or the eye wash station. Employee #69 agreed it is an accident hazard due to being accessible to residents.",2020-09-01
174,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2019-07-10,695,D,0,1,5N8D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to provide respiratory care services, consistent with professional standards of practice. This was true for one (1) of two (2) residents reviewed for respiratory services. During an observation it was discovered R52 was receiving her oxygen air flow at four 4 litters and not the ordered two (2)-three (3) liters. Resident identifier: R52. Facility census: 53. Findings included: a) R52 During a medical record review on 07/09/19, revealed the physician's orders [REDACTED]. An observation on 07/09/19 at 3:50 PM, it was discovered the oxygen concentrator for R52 had an air flow set on four (4) liters. An observation by E60, licensed practical nurse (LPN) verified the oxygen concentrator for R52 was providing an air flow of four (4) liters and not the ordered two (2) to three (3) liters as per orders.",2020-09-01
175,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2019-07-10,755,E,0,1,5N8D11,"Based on record review and staff interview, the facility failed to maintain complete and accurate drug records to ensure an account of all controlled medications (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence). This practice has the potential to affect all residents residing in the facility. Facility census: 53. Findings included: a) At 3:07 PM on 07/09/19, a review of the medication carts with Licensed Practical Nurse (LPN) #60 and LPN #76, revealed incomplete controlled substance medication count sheets on one (1) of two (2) med carts. LPN #76 reported the off going and the on coming nurses count the controlled medications together and then sign the Controlled Substances Shift Count form. LPN #60 confirmed the narcotic count sheet was incomplete on 07/04/19, 07/06/19 and 07/07/19. The Controlled Substance Shift Count form states at the top: Federal Drug Standards require accountability for all controlled substances. The count must be verified at the time there is a change of responsibility for the drugs from one nurse to another. Two (2) licensed nurses, oncoming and off going, will count the controlled drugs together and signed to verify the accuracy of the count. Any discrepancy, without exception, must immediately be reported to the Director of Nursing or Designee . The controlled substance shift count form for (MONTH) 2019, lacks numbers identifying the current medication counts on 07/04/19 day shift and 07/07/19 evening shift. In addition, the signature section is blank for Nurse II on 07/06/19 and 07/07/19 and blank for Nurse I on 07/07/19.",2020-09-01
176,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2019-07-10,756,F,0,1,5N8D11,"Based on policy review and staff interview, the facility failed to develop and maintain policies and procedures for the monthly drug regimen review that include time frames for physician notification and response of drug irregularities. This practice has the potential to affect all residents. Facility census: 53. Findings included: a) On 07/09/19 at 2:00 PM, review of the facility policy titled Medication Regimen Review with an implemented date of 12/06/18 and reviewed/revised date of 03/19/19, states the following (typed as written): 5. The pharmacist shall communicate any irregularities to the facility in the following ways: a. Verbal communication to the attending physician, Director of Nursing (DON), and/or staff of any urgent needs. b. Written communication to the attending physician, the facility's Medical Director, and the Director of Nursing. 6. Written Communications from the pharmacist shall become a permanent part of the resident's medical record. 7. Timelines and responsibilities for the Medication Regimen Review: a. The consultant pharmacist shall schedule at least one monthly visit to the facility, and shall allow for sufficient time to complete all required activities. b. The pharmacist shall communicate any recommendations and identified irregularities via written communication within 10 working days of the review. c. If the pharmacist should identify an irregularity that requires urgent action to protect a resident, the DON or designee is informed verbally. d. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. After review of the facility policy titled Medication Regimen Review on 07/09/19 at 2:30 PM, the DON and the Administrator agreed the facility policy does not contain time frames for physician notification and response of drug irregularities. The Administrator and DON explained the procedure is for the pharmacist to notify the physician by written communication. Both agree the policy should include time frames for the notification and response for the physician. The Administrator stated, The team and I will be determining an appropriate time frame and including it in the facility policy.",2020-09-01
177,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2019-07-10,761,F,0,1,5N8D11,"Based on observation, record review and staff interview, the facility failed to monitor the temperature of the medication refrigerator daily. This was true for one (1) of one (1) medication refrigerators and has the potential to affect all residents residing in the facility. Facility census: 53. Findings included: a) On 07/09/19 at 3:00 PM, a review of the medication room with Licensed Practical Nurse (LPN) #76, revealed the medication refrigerator temperature was not documented daily. The Refrigerator Temperature Log for (MONTH) 2019, was blank on 07/02/19 and 07/04/19. During this observation, LPN #76 confirmed the temperature log for the medication refrigerator was incomplete. LPN #76 reported the facility policy is the 3-11 nurse checks the temperature and documents the findings.",2020-09-01
178,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2019-07-10,812,F,0,1,5N8D11,"Based on observation and staff interview, the facility failed to ensure foods were stored under sanitary conditions after opening. During the kitchen tour it was discovered foods were not dated after opening. These food items were not stored in accordance with professional standards for food service safety. This had the potential to affect all residents receiving their nutrition from the kitchen. Facility census: 53. Findings included: a) Kitchen tour During the kitchen tour on 07/08/19 at 11:24 AM, it was discovered whipped cream, swiss cheese slices, bottled chocolate sauce and mustard were not dated after opening. These food items were not stored in accordance with professional standards for food service safety. In an interview on 07/08/19 at 11:35 AM the dietary manager (DM) verified the whipped cream, swiss cheese slices, chocolate sauce, and mustard were not dated after opening and the foods were not stored under proper food service safety.",2020-09-01
179,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2019-07-10,842,D,0,1,5N8D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure care and treatment was being provided in accordance with professional standards. This was true for two (2) of twenty- one (21) residents physician's orders [REDACTED]. R14 was not receiving oxygen therapy and still had an order for [REDACTED]. Facility census: 53. Findings include a) R14 During a medical record review on 07/10/19 revealed physician's orders [REDACTED]. In an interview with the Director of Nursing (DON) on 07/10/19 at 8:28 AM, verified the order for oxygen therapy should have been discontinued for R14 since she was no longer receiving oxygen. b) R52 During a medical record review on 07/09/19, revealed the physician's orders [REDACTED]. This order was not specific as to the correct amount of oxygen air flow R52 was to receive. In an interview with the Director of Nursing (DON) on 07/10/19 at 8:28 AM, verified the order for R52 was non-specific as to the correct amount of oxygen 2-3L she was to receive. For staff having to decide what air flow to provide 2-3L would be a decision outside their scope of practice.",2020-09-01
180,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2019-07-10,880,F,0,1,5N8D11,"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. The laundry room lacked separation between the soiled and clean laundry/linen area and no identified negative air flow. In addition a cracked and worn computer mouse pad in use located on a medication cart. This has the potential to affect all residents in the facility. Facility census: 53. Findings included: a) Laundry Room On 07/09/19 at 8:30 AM during a tour of the laundry room in the presence of Employee #56 and #47, discovered no separation between the soiled and clean linen, also lacking identified negative air flow. The washers and dryers are located in the same room within close proximity. While standing in the middle of the room could feel air flow descending from ceiling. Employee #56 and #47 explained the laundry room has been like that except last year the facility made the room across the hall with the laundry chute the soiled room. Employee #56 explained the procedure for collecting the soiled linen. The soiled linen is retrieved from the cart under the laundry chute, sorted then covered with a sheet and transported across the hall to the laundry room to place in the washers. At 8:45 AM on 07/09/19, the Administrator and the Assistant Administrator #69 stated, We thought we had fixed the laundry issue when our plan of correction was accepted. We moved the soiled laundry to the other room and sort it there before taking it across the hall. I now understand what you are saying that it is still soiled linen coming into a clean room Upon inquiry about separation between soiled and clean linen with washers and dryers being in the same room, the Administrator stated, We will brainstorm how to separate the washers and dryers. Whether by putting up a wall with negative air flow. Maybe move the washers to the room with the laundry chute, but will need to put water and drains in a cement floor. The Assistant Administrator #69 stated, We will have a plan and figure it out how to correct this issue with the laundry. b) medication cart An observation during medication administration on the North West side on 07/09/19, revealed Licensed Practical Nurse (LPN) #76 utilizing a cracked and worn mouse pad with missing corners. During an interview on 07/09/19, LPN #76 acknowledged the mouse pad was a sanitation concern and needed to be replaced. She reported she would ask for a replacement immediately.",2020-09-01
181,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2018-09-27,550,D,0,1,DL7D11,"Based on random observation, staff interviews and policy review, the facility failed to promote care for residents in a manner that maintained or enhanced dignity. The staff entered a resident's room without knocking, identifying themselves, or obtaining permission. This practice had the potential to affect a minimal number of residents. Resident identifiers: #24 and #31. Facility census 52. Findings included: a) Resident #24 and #31 During an observation of a resident room, on 09/24/18 at 11:30 AM, revealed Nurse Aide (NA) #40 walked into the room without knocking, identifying themselves, and asking for permission to enter Resident #24 and #31's room. NA #40 walked over to Resident #24's bed and stated, It is time to go to the bathroom. NA #40, turned around and left the room. A few minutes later NA#40 returned to room with NA #17 without knocking, identifying themselves, and asking for permission to enter Resident #24 and #31's room. The NA's walked over to Resident #24's bed. NA #17 went around to the far side of the bed. NA #40 was on the opposite side of the bed closest to the Resident in the A - bed and the door. NA#40 reached up and pulled down Resident #24's bed covers exposing the resident in an adult brief to her roommate with the door to the resident's room wide open for anyone to view inside. In an interview on 09/24/18 at 11:32 AM, NA #40 and #17, revealed the NA's forgot to knock on the residents door, identifying themselves and ask for permission prior to enter the room. The NA's also agreed they should have closed the entrance door to the room and pulled the curtain between the residents prior to pulling down Resident #24's bed covers. An interview on 09/24/18 at 12:00 PM, with the Assistant Administrator #13, she was informed of the observation above and she stated, I will address this matter. A review of the facility policy, on 09/27/18 at 2:00 PM, titled Promoting/Maintaining Resident Dignity with a revision date of 08/30/18, stated, Maintain Privacy. Staff shall knock on doors and properly announce themselves before entering.",2020-09-01
182,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2018-09-27,583,D,0,1,DL7D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on random observation, staff interview and policy review, the facility failed to provide privacy for a resident during personal care. Staff failed to pull the curtain while performing personal care and close the door to the resident room. This practice had the potential to affect a minimal number of residents. Resident identifier: #24. Facility census 52. Findings included: a) Resident #24 During an observation of room [ROOM NUMBER], on 09/24/18 at 11:30 AM revealed Nurse Aide (NA) #40, walked into the room without knocking, identifying themselves, and asking for permission to enter Resident #24 and #31's room. NA #40 walked over to Resident #24's bed, in which she resides in the b bed, and stated, It is time to go to the bathroom. NA #40, turned around and left the room. A few minutes later NA#40 returned to room with NA #17 without knocking, identifying themselves, and asking for permission to enter Resident #24 and #31's room. The NA's walked over to Resident #24's bed. NA #17 went around to the far side of the bed. NA #40 was on the opposite side of the bed closes to the Resident in the A - bed and the door. NA#40 reached up and pulled down Resident #24's bed covers exposing the resident in an adult brief to her roommate with the door to the resident's room wide open for anyone to view inside. In an interview on 09/24/18 at 11:32 AM, NA #40 and #17, revealed the NA's forgot to knock on the residents door, identifying themselves and ask for permission prior to enter the room. The NA's also agreed they should have closed the entrance door to the room and pulled the curtain between the residents prior to pulling down Resident #24's bed covers. An interview on 09/24/18 at 12:00 PM, with the Assistant Administrator #13, she was informed of the observation above and she stated, I will address this matter. A review of the facility policy, on 09/27/18 at 2:10 PM, titled Resident Right to Privacy During Care with a revision date of 08/30/18, stated, Privacy curtains are to be pulled during direct patient care. The facility's policy stated that additionally the staff will maintain privacy by knocking on doors and properly announcing themselves before entering resident rooms.",2020-09-01
183,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2018-09-27,761,D,0,1,DL7D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to ensure all multi-dose vials of insulin were dated when initially opened for used and needle-punctured. According to manufacturer's guidelines, [MEDICATION NAME]left in a multi-dose vial beyond twenty-eight (28) days of opening must be discarded. By not dating the multi-dose vial when initially opened, nursing staff had no way of knowing when to discard the vial. This practice had the potential to negatively impact the safety and/or potency of the insulin. This was evident for one (1) of ten (10) opened and used multi-dose vials of insulin observed. Resident identifier: #26. Facility census: 52. Findings include: a) Resident #26 Opened and used (needle punctured) multi-dose vials of insulin were observed on 09/27/18 at 10:53 AM. An opened and needle punctured vial of [MEDICATION NAME]for this resident contained no date to indicate when it had initially been opened for use. The label on the vial indicated pharmacy filled that prescription on 09/13/18. Licensed nurse employee #25 (E#25) was present at this time. She said staff should have dated this vial when initially opened to ensure that staff disposed of the vial twenty-eight (28) days after it was first opened for use. She said the [MEDICATION NAME]is used as sliding scale coverage for this resident's blood glucose checks per the glucometer. On 09/27/18 at 11:10 AM the director of nursing (DON) provided a copy of their policy titled Labeling of Medications and Biologicals with revision date of 08/30/18. Page two (2) and item number eight (8) of this policy stated All opened or accessed vials should be discarded within twenty-eight (28) days unless the manufacturer specified a different (shorter or longer) date for that opened vial. An interview was conducted with the administrator and assistant administrator on 09/27/18 at 1:15 PM. No further information was provided prior to exit.",2020-09-01
184,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2018-09-27,842,D,0,1,DL7D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , medical record review, and staff interview, the facility failed to ensure accurate medical transcription and documentation of a physician's orders [REDACTED]. A nurse wrote a physician's orders [REDACTED]. This order was transcribed onto the medication administration record at 2% strength. Nurses documented twelve (12) times they administered a 2% strength dose. However, pharmacy provided this prescription at 0.5% strength. Per a nursing drug handbook information, this ophthalmic ointment is only available at 0.5% strength. This was evident for one (1) of four (4) residents observed during medication pass out of thirty-four (34) medication administration observations. Resident identifier: #50. Facility census: 52. Findings included: a) Resident #50 During a medication administration observation on 09/26/18 at 9:10 AM, licensed nurse employee #26 (E#26) administered [MEDICATION NAME] 0.5% ophthalmic ointment to this resident's right eye. Observation of the electronic medical record found directive to administer [MEDICATION NAME] 2% ointment to the right eye. Review of the hard copy medical record revealed a hand-written physician's verbal order which was written by a nurse on 09/18/18 at 3:00 PM. This order directed to instill [MEDICATION NAME] ointment 2% topically to the right eye twice daily for seven (7) days related to irritation, redness, swelling. Review of the facility's Nursing (YEAR) drug handbook which was located at the nurses' station, found that [MEDICATION NAME] ophthalmic ointment is only available at the 0.5% strength. An interview was conducted with the assistant administrator on 09/26/18 at 9:15 AM regarding this scenario. She said this was a transcription error. The medication administration record (MAR) was reviewed on 09/26/18. The MAR contained a typed order to administer [MEDICATION NAME] ointment 2% to the right eye topically twice daily for seven (7) days. Nursing staff initialed on the electronic MAR twelve (12) times that they administered [MEDICATION NAME] 2% ointment to the right eye (including 09/26/18 for the 9:00 AM dose). An interview was conducted with the administrator and the assistant administrator on 09/27/18 at 1:15 PM where it was discussed that nursing on twelve (12) occasions documented on the MAR that they instilled [MEDICATION NAME] ointment 2%, although the pharmacy supplied [MEDICATION NAME] ophthalmic ointment 0.5%. They acknowledged their understanding. No further information was provided prior to exit.",2020-09-01
185,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2018-09-27,865,E,0,1,DL7D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility's quality assurance and performance improvement program (QAPI) / quality assessment and assurance (QAA) committee failed to identify and implement corrective action for quality deficiencies for which they should have been aware of to improve the lives of the residents. The facility failed to ensure that 10 out of 13 residents either received the appropriate pneumococcal immunization, or did not receive the pneumococcal immunization due to medical contraindication or refusal. These practices had the potential to affect more than a limited number of residents at the facility. Resident Identifiers: #26, #35, #42, #201, #24, #5, #101, #15, #4, #16, #17, #2, #30. Facility census: 52. Findings included: a) Staff interview at 11:13 on 09/26/18 with Licensed Practical Nurse (LPN) #70 revealed the facility did not routinely offer or administer the 13-valent pneumococcal conjugate vaccine (PVC13, Prevnar 13). The PVC13 is not readily available within the facility. LPN #70 also stated they only administer the PVC13 vaccine if it is specifically ordered by the physician, and the vaccine is not a standing order upon admission. b) Review of facility policy for Pneumococcal Vaccine state under Policy Explanation and Compliance Guidelines each resident will be offered a pneumococcal immunization unless it is medially contraindicated, or the resident has already been immunized, and prior to immunization the resident or resident's representative will have the opportunity to refuse. The policy also state the type of pneumococcal vaccine, 13-valent pneumococcal conjugate vaccine (PVC13, Prevnar 13) or 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23, [MEDICATION NAME] 23) offered will depend upon the recipient's age and suitability to pneumonia, in accordance with current Centers for Disease Control (CDC) guidelines and recommendations. Explanation of the facility's compliance guidelines indicate the residents medical record must include documentation that indicates the resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal. c) Centers for Disease Control (CDC) guideline for Pneumococcal Vaccine Timing for adults [AGE] years or older state for those who have not received any pneumococcal vaccines, or those with unknown vaccination history, administer 1 dose of 13-valent pneumococcal conjugate vaccine (PVC13, Prevnar 13) then administer 1 dose of 23-valent pneumococcal [MEDICATION NAME] vaccine ([MEDICATION NAME] 23, PPSV23) at least one (1) year later for most immunocompetent adults or at least eight (8) weeks later for adults with immunocompromising conditions. For those who have previously received 1 dose of PPSV23 at age [AGE] years or older and no doses of PCV13, administer 1 dose of PCV13 at least one year after the dose of PPSV23 for all adults, regardless of medical conditions. d) Review of facility's immunization report documentation dated (MONTH) 26th, (YEAR) reveals no documentation of refusal or administration of the 13-valent pneumococcal conjugate vaccine (PVC13, Prevnar 13) for residents #26, #35, #42, #201, #24, #5, #101, #15, #4, #16, #17, #2, #30. e) These findings were shared on 09/27/18 at 1:10 PM with the Administrator #12 and she stated, We were not aware that we need to offer the Prevnar 13 (13-valent pneumococcal conjugate vaccine (PVC13, Prevnar 13), we have ordered it. No further information regarding the immunization process was provided by the facility prior to exit.",2020-09-01
186,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2018-09-27,880,E,0,1,DL7D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interview the facility failed to maintain an effective infection control program designed to provide a safe and sanitary environment to help prevent the development of and transmission of communicable disease to the extent possible. A nursing assistant provided care to Resident #101 who was in contact precautions, without donning a gown or gloves. Licensed nurses cleaned the facility's two (2) resident shared glucometers improperly using 70% ethyl alcohol. One facility staff member was observed utilizing an improper hand-washing technique. The facility also failed to handle, store, and/or process linens in a satisfactory manner to prevent infection. These practices had the potential to affect more than a limited number of residents. Resident identifier: #101. Facility census: 52. Findings included: a) Resident #101 Observation on 09/24/18 at lunch time found nursing assistant employee #32 (E#32) entered the room of Resident #101 to deliver his lunch tray. A sign on the door conveyed that he was in contact precautions. An isolation cart sat outside his door in the hallway. E#32 did not don an isolation gown or gloves. She touched his bed linens with her bare hands. She touched his overbed tray with her bare hands. She picked up the bed control with her bare heads and raised the head of his bed. She helped him become positioned comfortably, and removed the brown plastic lid which covered the hot foods on his plate. At 12:19 PM E#32 walked down the hallway to the dining room where she passed this brown plastic plate cover through the kitchen window, where she placed it on top of other plate covers. She then used hand sanitizer and left the dining room. Review of the medical record on 09/25/18 found a physicians order dated 09/21/18 for contact isolation due to [MEDICAL CONDITION] resistant [DIAGNOSES REDACTED] aureus (MRSA) of the right foot wound. An interview was conducted with infection control registered nurse employee #11 (E#11) on 09/27/18 at 9:30 AM. When presented with the afore mentioned scenario, she said that staff should have gowned and gloved if they touched his bed. She said the lab faxed wound culture and gram stain results to them late in the day on 09/24/18. She said those results were negative. She provided a copy of a physician's orders [REDACTED]. This order was written, signed, and dated as 09/24/18 at 4:00 PM. She acknowledged that he was still in contact precautions at noon on 09/24/18 when observed. On 09/27/18 at 1:15 PM an interview was conducted with the administrator and the assistant administrator. They acknowledged this infection control infraction. No further evidence was provided prior to exit. b) Resident shared glucometers An interview was conducted with licensed nurse employee #47 (E#47) on 09/27/18 at 10:45 AM. She was asked when she cleans the glucometer and how she cleans it. She said she cleans the glucometer used for residents on her end of the hall with a 70% alcohol swab after each patient use. An interview was conducted with licensed nurse employee #25 (E#25) on 09/27/18 at 10:50 AM. She was asked when she cleans the glucometer and how she cleans it. She said she cleans the glucometer used for residents on her end of the hall with a 70% alcohol swab after each patient use. At 11:00 AM on 09/27/18 an interview was conducted with the director of nursing (DON). She provided a policy titled Glucometer Disinfection with revision date 08/27/18. Their policy directed that the facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. It further stated that the glucometers should be disinfected with a wipe pre-saturated with an EPA (Environmental Protection Agency) registered healthcare disinfectant that is effective [MEDICAL CONDITION](human immunodeficiency virus), [MEDICAL CONDITION] and [MEDICAL CONDITION] virus. The DON produced a canister of Sani-Cloth wipes. She said that staff must use these Sani-Cloth wipes to clean and disinfect the glucometers after each use. She said that 70% alcohol was not acceptable. The label on this canister of Sani-Cloth wipes conveyed this product was a germicidal disposable wipe that was bactericidal, tuberculocidal, and virucidal in two (2) minutes. The label contained a statement that the wipes are effective against bacteria, multi-drug resistant bacteria, viruses, bloodborne pathogens, and pathogenic fungi. An interview was conducted with the administrator and the assistant administrator on 09/27/18 at 1:15 PM. They acknowledged their understanding of this issue. At 2:00 PM on 09/27/18, the assistant administrator provided a list of names of nine (9) residents in the facility who receive accu-checks at least daily. c) During observation of laundry pick up on 09/26/18 at 9:16, Laundry Supervisor (LS) #72 wore the same gloves throughout pick-up of all soiled linens on A wing unit, and while gathering soiled linens from various resident's rooms. LS #72 removed gloves after transferring all the soiled linen bags into the laundry shoot from linen cart. LS #72 did not wash her hands after removing gloves before initiating the next task. Compliance guidelines within the facility's hand washing policy state that all facility personnel must wash their hands for twenty seconds using the appropriate technique after handling soiled dressings, linens, contaminated equipment, and after removing gloves. LS #72 failed to utilize proper hand hygiene to prevent the spread of infection during observation on 09/26/18 at 9:40 AM. LS #72 was observed washing hands with soap and water, turning off water facet with clean hands, then drying hands with paper towels, therefore re-contaminating hands. Facility policy for Hand Washing states that proper hand washing technique is: Use water to wet hands. Apply soap. Rub hands and clean between fingers briskly for 20 seconds. Rinse under warm water. Towel dry with clean disposable towels. Turn off faucet with clean paper towels. d) The facility failed to handle, store, process, and transport linens so as to prevent the spread of infection. Observation of the laundry room on 09/26/18 at 9:22 AM, in the presence of the Laundry Supervisor (LS) #42 reveled the following: No separation between the soiled and clean linen areas. No identified negative airflow from the clean to soiled areas. During this observation LS #42 acknowledged the laundry room lacked separation between the clean and soiled areas and noted she was not aware negative air flow was needed, they were told to crack a window while air conditioning unit was on. LS #42 did not wear any protective barrier, such as apron or disposable gown, while handling soiled or clean linens, while allowing linens to touch her uniform and stated, Dirty laundry is always in a linen bag when they are sent down the laundry shoot, so we don't contaminate the area. LS #42 was observed at 9:30 AM on 09/23/18 removing a clean resident privacy curtain from the washer, allowing the linen to touch the floor and her uniform, then hanging the clean linen on a clothes line in the laundry room after the clean linen came into contact with staff's contaminated uniform. Review of facility policy for handling soiled linen state linen should not be allowed to touch the uniform and floor and should be handled as little as possible, with minimum agitation to avoid contamination of air, surfaces, and person. On 09/26/18 at 11:00 AM informed Assistant Administrator(AA) #13 of infection control issues with laundry and asked for policy on soiled linen, AA #13 advised she was unaware of requirements for laundry area environment requirement of separation of clean and soiled area and have never been cited for an issue.",2020-09-01
187,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2018-09-27,883,E,0,1,DL7D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, policy review and documentation review, the facility failed to ensure 10 out of 13 sample residents were given opportunity to receive, refuse, or to have contraindication determined for the appropriate pneumococcal vaccination to be administered. Resident identifiers: #26, #35, #42, #201, #24, #5, #101, #15, #4, #16, #17, #2, #30. Facility census: 52. Findings included: a) Staff interview at 11:13 on 09/26/18 with Licensed Practical Nurse (LPN) #70 revealed the facility did not routinely offer or administer the 13-valent pneumococcal conjugate vaccine (PVC13, Prevnar 13). The PVC13 is not readily available within the facility. LPN #70 also stated they only administer the PVC13 vaccine if it is specifically ordered by the physician, and the vaccine is not a standing order upon admission. b) Review of facility policy for Pneumococcal Vaccine state under Policy Explanation and Compliance Guidelines each resident will be offered a pneumococcal immunization unless it is medially contraindicated, or the resident has already been immunized, and prior to immunization the resident or resident's representative will have the opportunity to refuse. The policy also state the type of pneumococcal vaccine, 13-valent pneumococcal conjugate vaccine (PVC13, Prevnar 13) or 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23, [MEDICATION NAME] 23) offered will depend upon the recipient's age and suitability to pneumonia, in accordance with current Centers for Disease Control (CDC) guidelines and recommendations. Explanation of the facility's compliance guidelines indicate the residents medical record must include documentation that indicates the resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal. c) Centers for Disease Control (CDC) guideline for Pneumococcal Vaccine Timing for adults [AGE] years or older state for those who have not received any pneumococcal vaccines, or those with unknown vaccination history, administer 1 dose of 13-valent pneumococcal conjugate vaccine (PVC13, Prevnar 13) then administer 1 dose of 23-valent pneumococcal [MEDICATION NAME] vaccine ([MEDICATION NAME] 23, PPSV23) at least one (1) year later for most immunocompetent adults or at least eight (8) weeks later for adults with immunocompromising conditions. For those who have previously received 1 dose of PPSV23 at age [AGE] years or older and no doses of PCV13, administer 1 dose of PCV13 at least one year after the dose of PPSV23 for all adults, regardless of medical conditions. d) Review of facility's immunization report documentation dated (MONTH) 26th, (YEAR) reveals no documentation of refusal or administration of the 13-valent pneumococcal conjugate vaccine (PVC13, Prevnar 13) for residents #26, #35, #42, #201, #24, #5, #101, #15, #4, #16, #17, #2, #30. e) These findings were shared on 09/27/18 at 1:10 PM with the Administrator #12 and she stated, We were not aware that we need to offer the Prevnar 13 (13-valent pneumococcal conjugate vaccine (PVC13, Prevnar 13), we have ordered it. No further information regarding the immunization process was provided by the facility prior to exit.",2020-09-01
188,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2017-10-18,323,E,0,1,XKNG11,"Based on observation and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Observations during Stage 1 of the Quality Indicator Survey (QIS) found a Soiled Utility closet on Wing one (1) was unlocked with chemicals stored on a shelf, and the Clean Room, which contained biologicals. This had the potential to affect more than an isolated number of residents. Facility census: 55 Findings include: a) Observations of Wing one (1) On 10/16/17 at 10:51 a.m., during an observation on Wing one (1), it was discovered the Soiled Utility closet was unlocked. In the Soiled Utility closet there was one (1) gallon container of Pinesol and one (1) gallon of Lysol mixtures on a shelf. The unlocked door allowed any wandering resident access to this closet with the potential to ingest these hazardous chemicals. During an interview with Employee #80, licensed practical nurse (LPN) on 10/16/17 at 10:52 a.m., verified the Soiled Utility closet was always unlocked, she did agree these chemicals should not be stored in an unlocked area accessible to wandering residents. b) Clean Utility Room A random observation on 10/17/17 at 8:00 a.m. discovered an unlocked room with a plaque on the door stating, clean utility with no lock on the door or door knob. The room contained various supplies which included a drawer containing numerous packets of INZO Barrier Cream with 5% dimethicone (uses include: temporarily protects - and helps relieve chapped or cracked skin - minor cuts), written on the packets was Warning which stated (typed as written): Keep this and all drugs out of reach of children for external use only. Avoid contact with eyes. When accompanied by Licensed Practical Nurse (LPN) #22 to the clean utility room on 10/17/17 at 8:05 a.m., she verified and agreed the door is unlocked with no means of locking the room. She stated, The door has never been locked, commenting the room contains clean supplies which include as Foley catheter insertion kits, dressing supplies, isolation gowns, isolation masks and syringes. Upon opening the cabinet drawer LPN #22 explained, This drawer is full of barrier cream for residents. After reading the Warning on the package label, she stated, We do have wandering residents and this could pose an accident hazard if they got a hold of these packages. I will talk to the Director of Nursing (DON) about this. At 8:20 a.m. on 10/17/17 the DON reported, I will have a lock put on the door (clean utility room). Agree it could potentially be a accident hazard to wandering residents. On 10/17/17 at 8:45 a.m. observed a maintenance employee installing a door knob with a lock on the door to the clean utility room.",2020-09-01
189,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2017-10-18,371,E,0,1,XKNG11,"Based on observation and staff interview the facility failed to store food items under sanitary conditions. Bottles of thickened liquids were found not dated when opened. This practice has the potential to affect more than limited number of residents. Census: 55. Findings include: a) During the initial tour of the dietary department at 10:45 a.m. on 10/16/17 with the certified dietary manager, the following issue was revealed: plastic bottles containing thickened liquids such as prune juice, apple juice and water were found opened but not dated. This would not allow the dietary staff to determine how long the product had been opened and the chance for contamination to be greater.",2020-09-01
190,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2017-10-18,431,E,0,1,XKNG11,"Based on observation and staff interview, the facility failed to ensure it provided permanently affixed compartments for storage of controlled medications and other drugs subject to abuse (Fentanyl, Norco, Morphine Sulfate, Oxycontin, Roxicodone, and Percocet). This was found in one (1) of one (1) medication storage room. This practice has the potential to affect more than an isolated number. Resident census: 55. Findings include: a) An observation of the metal cabinet in the medication storage room on 10/17/15 at 2:20 p.m., with Registered Nurse (RN) #79, revealed an unsecured clear white plastic box sealed with a zip tie and labeled: Attention All Nurses DEA (Drug Enforcement Administration) STOP Controlled Substance. The box contained the following: --5 Acetaminophen / Codeine (Tylenol #3) --5 Alprazolam (Xanax) 0.25 milligrams (mg) --3 Clonazepam (Klonopin) 0.5 mg --3 Diphenoxylate Atropine (Lomotil) 2.5 mg --2 Fentanyl (Duragesic) 25 mg patch --2 Fentanyl (Duragesic) 50 mg patch --6 Hydrocodone/Apap (Norco) 5/325 mg --6 Hydrocodone/Apap (Norco) 7.5/325 mg --6 Hydrocodone/Apap (Norco) 10/325 mg --5 Lorazepam (Ativan) 0.5 mg --5 Morphine Sulfate ER (extended release) (MS Contin) 15 mg --2 30 milliliter (ml) bottles Morphine Sulfate (Roxanol) 20 mg/ml --3 Oxycodone SR (sustained release) (Oxycontin) 10 mg --5 Oxycodone IR (immediate release) (Roxicodone) 5 mg --6 Oxycodone/Apap (Percocet) 5/325 mg --3 Phenobarbital (Phenobarb) 32.4 mg --3 Tramadol (Ultram) 50 mg --3 Zolpidem (Ambien) 5 mg This clear white plastic container was not secured to the metal cabinet and was demonstrated to be easily removed. RN #79, confirmed the clear white box containing controlled substances was not secured to the cabinet and could be removed easily. During an interview on 10/17/17 at 2:35 p.m., the Director of Nursing (DON) agreed the drug box was not secured to the cabinet. She reported the pharmacist routinely checks the drug box and never informed the facility that the box needed to be permanently affixed to the cabinet.",2020-09-01
191,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2017-10-18,441,E,0,1,XKNG11,"Based on observation, policy review and staff interview, the facility failed to maintain an effective infection control program to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. Breaches in infection control practices were observed during medication administration for Resident #7 and Resident #18 and during a random observation of the clean utility room involving a soiled laundry chute. This practice has the potential to affect more than an isolated number of residents residing in the facility. Resident identifiers: #7 and #18. Facility census: 55. Findings include: a) Resident #7 After a medication administration pass observation for Resident #7 on 10/17/17 at 8:04 a.m. Licensed Practical Nurse (LPN) #80 performed hand hygiene with soap and water for fourteen (14) seconds then proceeded to turn off the faucet with the same paper towel used to dry her hands. b) Resident #18 After a medication administration pass observation for Resident #18 on 10/17/17 at 8:17 a.m. LPN #80 performed hand hygiene with soap and water for seventeen (17) seconds then proceeded to turn off the faucet with the same paper towel used to dry her hands. Immediately following the observations LPN #80 stated, I thought I washed my hands for 20 seconds but maybe I did it too quickly. She agreed and verified that the same paper towel used to dry her hands was used to turn off the water faucet. Reported I didn't know I was supposed to get a clean dry paper towel but it makes sense that it would be wet and cause contamination from the faucet. Our hand-washing policy is to wash our hands for twenty (20) seconds). Review of the facility hand-washing policy provided by the Director of Nursing (DON) on 10/17/17 at 8:55 a.m. with titles from Centers for Medicare & Medicaid Services (CMS) and World Health Organization (WHO) with a date of 2009 stated the following (typed as written): .Rub hands and forearms briskly for 20 seconds . The (YEAR) hand hygiene recommendations from the Centers for Disease Control (CDC) include: Recommended techniques for washing hands with soap and water include wetting hands first with clean, running warm water, applying the amount of product recommended by the manufacturer to hands, and rubbing hands together vigorously for at least 20 seconds covering all surfaces of the hands and fingers; then rinsing hands with water and drying thoroughly with a disposable towel; and turning off the faucet on the hand sink with a dry disposable paper towel. The DON reported on 10/17/17 at 9:00 a.m., I have never heard of turning off the faucet with a clean paper towel and we follow the CMS rules. I told my nurse to wash her hands for twenty-five (25) seconds just to be safe. Maybe she counted too fast or was nervous because she was being watched. c) Clean Utility Room with laundry chute A random observation on 10/17/17 at 8:00 a.m. discovered an unlocked room with a plaque on the door stating, clean utility with a soiled laundry chute (A vertical shaft in a building down which dirty clothes and linens can be dropped, to land in a laundry area on a lower floor) located inside the room on the right wall. The stainless steel door to the laundry chute was ajar and not latched with the barrel bolt lock located on the lower part of the door and frame. The door and door frame was soiled and a build up of grime on the inside of the door including the chute itself. Accompanied by LPN #22 to the clean utility room on 10/17/17 at 8:05 a.m., she commented, the room contains clean supplies which include as Foley catheter insertion kits, dressing supplies, isolation gowns, isolation masks, syringes etc. She verified the laundry chute door was ajar and not latched as it is always supposed to be. During the interview a random employee opened the door, pulling a cart containing soiled laundry/linen to the door and place the cloth bags of linen down the laundry chute. Upon inquiry regarding soiled linen being transported into a clean utility room with clean supplies which included a box of isolation masks with the top open, LPN #22 explained this is the way we have always done it and guess it could be an infection control issue. During an observation accompanied by the DON on 10/17/17 at 8:25 a.m., she agreed and verified the laundry chute Door and door frame were soiled. She stated, Certainly needs cleaned and I think housekeeping is responsible for cleaning it. The DON agreed and commented, With the laundry chute used for soiled linen certainly poses an infection control issue with dirty items being brought into a clean area. The door to the chute is always supposed to be shut and locked. Employee #17 verified on 10/17/17 at 10:50 a.m. that the laundry chute door in the clean utility room was again ajar and not latched shut. She stated, They just bring in the bags and put them down the laundry chute. I guess with the door open and not locked that air from the chute could certainly circulate in this room causing an infection control issue. On 10/17/17 at 11:16 a.m. discovered the end of laundry chute is housed downstairs in housekeeping supply room. Employee #15 demonstrated that a cart is brought over to the chute, soiled laundry is removed and transported across the hallway to the soiled laundry room. She commented, The laundry stays in the chute for a while until someone from laundry comes and gets it. I am not sure who is supposed to clean it (laundry chute). Employee #8 requested to view the clean utility room on 10/18/17 at 8:15 a.m. Upon entering the clean utility room the door to the laundry chute was again found to be ajar and unlatched. She verified this observation and stated, It should always be completely shut and securely latched. No one was sure who was supposed to clean the laundry chute and the door but now it is on a cleaning schedule to be done by housekeeping. Agree it is an infection control issue and we are looking at ways to correct it.",2020-09-01
192,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2019-04-11,578,D,0,1,M7ZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure all elements of the advance directive were completed for three (3) of 14 residents reviewed during the long-term care survey process. Facility identifiers: #1, #6, #27. Facility census: 39. Findings included: a) Resident #1 Review of Resident #1's West Virginia Physician order [REDACTED]. No length of time had been entered into the space provided on the form. During an interview on 04/09/19 at 1:30 PM, Social Worker #4 agreed Resident #1's POST form did not specify the length of time for the IV fluids trial period. On 4/9/2019 at 2:25 PM, a progress note was written which stated, This DSS (Director of Social Services) and administrator spoke with resident's HCS (Health Care Surrogate) (name of health care surrogate) this date regarding resident's POST form. This DSS asked for clarification of a defined trial period of IV fluids and HCS stated that 1 month would be ideal. This DSS and administrator assured HCS that this would be written in and if the HCS would ever like to change it this can be done. No concerns noted at this time. Will continue to monitor and report any new changes. b) Resident #6 Review of Resident #6's West Virginia Physician order [REDACTED]. The defined trial period was not stated. The POST form did not include an area on the form to indicate the defined trial period. The POST form was dated 05/15/2006 and had been reviewed on 09/26/17 according to the form. During an interview on 04/09/19 at 1:30 PM, Social Worker #4 agreed Resident #6's POST form did not specify the defined trial period for IV fluids or feeding tube. Social Worker #4 stated this POST form was an old form. She stated Resident #4's Health Care Surrogate would be contacted to clarify the interventions and complete a new form. On 04/11/19 at 9:46 AM, Social Worker #4 stated an updated POST form had been completed for Resident #6. c) Resident #27 Review of Resident #27's medical records revealed a West Virginia Physician order [REDACTED]. The POST form had not been signed by the resident's medical power of attorney or health care surrogate. Resident #27 did not have medical decision-making capacity. During an interview on 04/09/19 at 1:30 PM, Social Worker #4 agreed Resident #27's POST form had not been signed by the resident's medical power of attorney or health care surrogate. On 04/11/19 at 9:46 AM, Social Worker #4 stated Resident #27's POST form had been signed by the resident's representative.",2020-09-01
193,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2019-04-11,584,D,0,1,M7ZP11,"Based on observation, resident interview, and staff interview , the facility failed to provide a safe clean home like environment to the extent possible. A random observation of a dependent resident's bedside phone revealed the phone to be grossly dirty and in need of cleaning and sanitizing. This practice had the potential to affect more than limited number of residents. Resident identifier: #17. Facility census: 39. Findings included: a) Resident #17 Observation of Resident#17's bedside telephone, on 04/10/19 at 9:20 AM, revealed a lot of built up crusty dirt and debris inside the phone cradle, where the ear piece of the phone rested when not in use. Inspection of the earpiece revealed some dried debris coating the outer surface of the earpiece that would lay against the resident's ear when she spoke on the phone. This surveyor asked the resident, When was the last time the phone had been cleaned? The resident replied, I don't remember when it was ever cleaned. This surveyor pointing at the phone, asked the resident if she talked on that phone. The resident replied, Oh yes, I talked to my daughter all the time. On 04/10/19 at 9:23 AM, this Surveyor went into the hallway and asked nurse aide (NA#13) to step into resident 17's room. NA#13 was asked to pick up the resident's phone and look at the cradle. The nurse aide picks up the phone and looking at the cradle gasped, Oh! I will get housekeeping to clean this immediately.",2020-09-01
194,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2019-04-11,641,D,0,1,M7ZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, facility failed to accurately complete the Minimum Data Set (MDS) to reflect Resident #19's urinary continence status. This was true for one (1) of fourteen (14) sampled residents. Resident identifiers: #19. Facility census: 39. Findings included: a) Resident #19 Review of Resident #19's medical records, found the resident was admitted on [DATE]. [DIAGNOSES REDACTED]. Neuromuscular dysfunction of bladder is a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition. Review of Resident #19's admission MDS assessment with an assessment reference date (ARD) of 03/01/19, which found section H - Bladder and Bowel indicates the resident has an indwelling Foley catheter. Under Section H 0300 urinary incontinence the MDS was coded 3, to indicate the resident is always incontinent (no episodes of incontinence). Review of the Resident Assessment Instrument (RAI) the appropriate answer is Code 9, not rated: if during the 7-day look-back period the resident had an indwelling bladder catheter, condom catheter, ostomy, or no urine output (e.g., is on chronic [MEDICAL TREATMENT] with no urine output) for the entire 7 days. Interview with the Director of Nursing (DON) on 04/10/19 at 12:15 p.m., after review of the admission MDS with ARD of 03/01/19, she confirmed the MDS was coded in error. She confirmed the answer should have been 9 not 3. She confirmed the admission MDS with ARD of 03/01/19 was inaccurate.",2020-09-01
195,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2019-04-11,656,D,0,1,M7ZP11,"**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 develop a care plan to include the contact information of a resident's Hospice service provider; and implement care plan interventions related to oxygen therapy, positioning, and skin integrity. This was true for three (3) of fourteen (14) resident care plans reviewed during the annual long-term care survey process. This practice had the potential to affect more than a limited number of residents. Resident identifier: #2, #17, and #1. Facility census: 39. Findings included: a) Resident #2 (R#2) Review of records revealed R#2 was admitted to Hospice services on 07/09/18 and was admitted to the facility on [DATE]. Review of R#2's care plan, on 04/10/19 at 2:54 PM, revealed the Hospice 24-hour contact information was not included in the care plan. An interview, on 04/10/19 at 3:50 PM with the MDS nurse responsible for developing resident care plans, confirmed R#2 care plan was developed without including the Hospice 24-hour contact information. The MDS nurse said the resident already had Hospice services when she came to the facility, and the Hospice 24-hour contact information should have been included when the facility first developed the resident's care plan. The MDS nurse stated she would update the care plan now with the Hospice 24-hour contact information. b) Resident #17 (R#17) Review of the resident's quarterly minimum data set (MDS) with an assessment reference date (ARD) 02/18/19, on 04/10/19 at 09:46 AM, revealed the resident has clear speech, makes them self-understood and understands. The resident's Brief Interview for Mental Status (BIMS) score was twelve (12) indicating the resident is moderately impaired. R#17 did not exhibit any behaviors. The resident is totally dependent with bed mobility, meaning full staff performance every time. The resident needs supervision with eating and is totally dependent with all other activities of daily living (ADLs). ADLs include bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. Resident has impairment in both lower extremities. Some [DIAGNOSES REDACTED]. 1. Oxygen Review of R#17's care plan, on 04/10/19 at 10:28 AM, revealed the resident has chest pain related to [MEDICAL CONDITION] with an intervention: Oxygen (02) via nasal prongs as ordered. Observations, on 04/10/19 at 8:44 AM, revealed resident's oxygen flow meter was set close to 4L (liters per minute). Review of the current orders revealed, oxygen at 2L per nasal cannula continuous related to decrease O2 sats (blood oxygen saturation). On 04/10/19 at 9:01 AM, Registered Nurse (RN#91) and RN#3 entered resident #17's room. This surveyor requested RN#91 look at the oxygen meter to see what rate the flow meter was on. RN#91 stated the 02 was on 3 1/2L, confirming the oxygen rate was not 2L as was ordered and indicated in the care plan. RN#91 adjusted the resident's oxygen rate to 2L as ordered and care planned. 2. Positioning Review of R#17's care plan, on 04/10/19 at 10:28 AM, revealed the resident has an activities of daily living (ADL) self-care performance deficit. Two of the interventions include, Bed mobility: The resident requires extensive to total assistance with repositioning at all times. Transfer: The resident requires Hoyer lift and is dependent on 2 staff for transfer. On 04/08/19 at 12:35 PM, during an interview with the resident, restorative nurse aide (NA#61) entered the room with the resident's lunch tray and sat it on the over bed table. opened items for the resident on the tray, placed butter on the resident's potatoes, NA#61 assisted the resident with her napkin, raised the head of the resident's bed to about seventy five (75) degrees from (45) degrees, and pleasantly ask the resident if there was anything else she wanted, then left the room. Before leaving the nurse aide did not check to make sure the resident could reach items on her tray, or if R#17 was positioned comfortably and/or in good body alignment to facilitate eating. R#17 was lying low in the bed before NA#61 raised the head of the bed. However, when the nurse aide raised the head of the bed the resident slid down even more into the bed. The resident's lower back was curved and raised off the bed surface unsupported in the bend of the bed. The resident's upper torso was hunched over and her chin pointed down to her neck. R#17 struggled to reach the items on her lunch tray. The resident's body positioning was poorly aligned and did not facilitate affective swallowing. This surveyor asked the resident, Are you comfortable? The resident replied, No, I'm not comfortable! This surveyor asked the resident if she could straighten her own self up in the bed, and R#17 answered, No, I can't do it, I need help. This surveyor requested the resident use her call light to get assistance to help straighten her up in the bed. NA#61 answered the call light, and agreed the resident needed pulled up in the bed and repositioned. NA#61 left the room and returned with NA#2 to assist in repositioning the resident in her bed after surveyor intervention. c) Resident #1 Review of Resident #1's medical records revealed the resident had a skin tear on her coccyx, a skin tear on her foot, and a deep tissue injury on her left hip. Weekly wound assessments of the skin tear on the foot and the deep tissue injury on the hip had been documented in the progress notes and on a wound weekly observation tool. The skin tear on the coccyx was first observed on 03/26/19 and the wound was measured as 5 cm x 2.5 cm at that time. No further assessments of the coccyx skin tear could be located in the medical records. Resident #1's comprehensive care plan contained the focus, I have a potential for impairment to skin integrity r/t (related to) fragile skin. The interventions included, I will have weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Resident #1 had an order for [REDACTED]. Sure Site is a transparent dressing used to protect a wound while it heals. On 04/11/19 at 10:30 AM, Assistant Director of Nursing (ADoN) #23 was observed changing Resident #1's coccyx Sure Site dressing. ADoN #23 stated she was going to have the physician assess Resident #1's coccyx skin tear to determine if a different treatment and dressing would be beneficial. Resident #1's coccyx wound was addressed in the following progress notes: (The notes are typed as written.) - 03/26/19 at 6:50 PM: Skin tear remains suresite C/D/I (Clean, dry, intact) . - 3/27/19 at 3:04 AM: Skin tear suresite C/D/I . - 03/27/19 at 11:30 AM: Resident with skin tear to her coccyx. Sure site is CDI . - 03/28/19 at 6:25 PM: .Skin tear remains to coccyx . - 03/29/19 at 7:50 PM: .Skin tear remains to coccyx . - 03/30/19 at 5:09 AM: Skin tear remains to coccyx . - 03/30/19 at 6:51 PM: .Skin tear remains to coccyx . - 03/31/19 at 2:44 AM: .Skin tear remains to coccyx . - 04/02/19 at 2:53 AM: .Skin tear remains to coccyx . - 04/03/19 at 1:11 AM: .Skin tear remains to coccyx . - 04/06/19 at 12:37 AM: .Skin tear remains to coccyx . During an interview on 04/11/19 at 1:05 PM, the Director of Nursing (DoN) stated she was unable to locate updated assessments of Resident #1's coccyx skin tear. The DoN stated skin tears do not require assessments on the wound weekly observation tool. During an interview on 04/11/19 at 1:56 PM, the Administrator and Director of Nursing were informed the facility failed to implement Resident #1's comprehensive care plan intervention to perform weekly treatment documentation including measurement of each area of skin breakdown. The Administrator and Director of Nursing had no further information regarding the matter. No information was provided through the completion of the survey.",2020-09-01
196,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2019-04-11,684,D,0,1,M7ZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure Resident #4 received treatment and care with professional standards of practice and the comprehensive person-centered care plan. This was true for one (1) of fourteen (14) residents reviewed. Resident identifier: #4. Facility census: 39. Findings included: a) Resident #4 Review of medical records for Resident #4 found a physician's orders [REDACTED]. oxygen saturation level below 92% (percent) and Check oxygen saturation (SPO2) every shift. Review of the Medication Administration Records (MAR) for 01/01/19 through 04/09/19 found the MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 04/10/19 at 1:15 p.m., found the staff had failed to document the results of the SPO2 % as the physician order [REDACTED]. She confirmed the nurses were not following the physician's orders [REDACTED].>",2020-09-01
197,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2019-04-11,842,D,0,1,M7ZP11,"**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 record for three (3) of 14 residents reviewed during the long-term care survey process. The facility failed to document wound care on Resident #1's Treatment Administration Record. The facility failed to ensure Resident #27's tube feeding order contained all required elements. The facility failed to ensure Resident #10's [DIAGNOSES REDACTED]. Resident identifiers: #1, #27, #10. Facility census: 39. Findings included: a) Resident #1 Resident #1 had an order for [REDACTED]. Sure Site is a transparent dressing used to protect a wound while it heals. On 04/11/19 at 10:30 AM, Assistant Director of Nursing (ADoN) #23 was observed changing Resident #1's coccyx Sure Site dressing because the dressing was soiled with stool. The Sure Site dressing removed had a date of 04/10/19 on it. Resident #1's Treatment Administration Record did not include the order to change the resident's coccyx dressing every seven (7) days and as needed. Resident #1's progress notes contained notations that the Sure Site dressing was clean, dry, and intact, but did not contain information regarding when the dressing was changed. During an interview on 04/11/19 at 1:01 PM, the Director of Nursing agreed Resident #1's coccyx dressing change was not included on the resident's Treatment Administration Record. She stated the resident's coccyx dressing was changed frequently because the resident was incontinent of stool, soiling the dressing. During an interview on 04/11/19 at 1:56 PM, the Administrator was informed Resident #1's coccyx dressing change was not included on the resident's Treatment Administration Record. She had no further information regarding the matter. No information was provided through the completion of the survey. b) Resident #27 Resident #27 had the following tube feeding order: [MEDICATION NAME] 1.2 Cal Liquid (Nutritional Supplements). Give 240 cc via [DEVICE] every 4 hours for sole source feeding give with 120cc h2o flush. (Typed as written.) [DEVICE] feedings can be administered by bolus, which involves the feeding being administered with a syringe over a short or period of time, by infusion over a specified, longer period of time, or by continuous infusion. Resident #27's tube feeding order did not specify how the feeding was to be administered. On 04/11/19 at 11:10 AM, Licensed Practical Nurse (LPN) #62 was observed administering Resident #27's tube feeding. She administered the tube feeding by bolus, using a syringe, over approximately ten (10) minutes. During an interview on 04/11/19 at 12:58 PM, the Director of Nursing (DoN) was informed Resident #27's tube feeding order did not specify how the feeding was to be administered. The DoN confirmed the tube feeding was to be administered by bolus. The DoN stated Resident #27 tolerated bolus tube feedings best. During an interview on 04/11/19 at 1:56 PM, the Administrator was informed Resident #27's tube feeding order did not specify how the feeding was to be administered. She had no further information regarding the matter. No information was provided through the completion of the survey. c) Resident #10 Resident #10 had an order for [REDACTED].#10's comprehensive care plan also contained the focus, The resident uses antidepressant medication r/t (related to) depression. Resident #10's [DIAGNOSES REDACTED]. During an interview on 04/10/19 at 10:50 AM, the Director of Nursing (DoN) was informed Resident #10's [DIAGNOSES REDACTED]. During an interview on 04/10/19 at 2:08 PM, the Administrator confirmed a [DIAGNOSES REDACTED].#10's [DIAGNOSES REDACTED].",2020-09-01
198,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2019-04-11,880,D,0,1,M7ZP11,"Based on observation, resident interview, and staff interview , the facility failed to implement an ongoing infection prevention and control program (IPCP) to help prevent, recognize, and control the onset, cross-contamination, and spread of infection to the extent possible. A random observation of two nurse aides tidying a dependent resident's bed revealed a breach in infection control principles when a nurse aide held the used bed linens against her uniform. This practice had the potential to affect more than limited number of residents. Resident identifier: #17. Facility census: 39. Findings included: a) Resident #17 Observations, on 04/10/19 at 5:22 PM, revealed Nurse Aide (NA#25) and Nurse Aide (NA#40) in Resident (R#17)'s room. The resident was lying in the bed, NA #25 was straightening the bed linens, and NA#40 was standing at the left side foot of the resident's bed with her arms full of a large amount of wadded up blankets against the uniform of her upper body. Interview with the nurse aides confirmed the blankets NA#40 was holding had just came off the resident's bed. NA #25 said she was straightening the bed and piled the blankets in NA#40's arms to get them out of her way as she was fixing the bed. Both NA #25 and NA#40 confirmed and acknowledged holding used bed linens against their uniform was a breach in infection control principles they were taught in their nurse aide training. According to the Centers for Medicare & Medicaid Services (CMS) laundry includes resident's personal clothing, linens (i.e. sheets, blankets, pillows), towels . CMS Guidance for handling laundry includes, The facility staff should handle all used laundry as potentially contaminated and use standard precautions. CMS Guidance states one of the practices facilities should use, is; Staff should handle soiled textiles/linens with minimum agitation to avoid the contamination of air, surfaces, and persons. Guidance from CMS also states, The facility practices must include how staff will handle and transport the laundry with appropriate measures to prevent cross-contamination. This includes but is not limited to the following; Contaminated linen and laundry bags are not held close to the body . ;",2020-09-01
199,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2017-04-19,157,E,0,1,HZCX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, responsible party interview, and resident interview, the facility failed to notify the responsible party/resident of changes in the residents medications and treatments for three (3) of four (4) residents reviewed for the care area of notification of change during Stage 2 of the Quality Indicator Survey (QIS). This was true for Resident #49, #44 and #8. Resident Identifiers: #49, #44 and #8. Facility Census: 39. Findings Include: a) Resident #49 A review of Resident #49's medical record, at 8:58 a.m. on 04/18/17, found Resident #49 was declared incapacitated by her attending physician on 12/29/16. Also contained in the record was the residents appointment of a Power of Attorney (POA) which was completed on 01/28/11. This POA included medical decision making power. Further review of the record found the following physician orders: --Order dated 01/18/17 for Vitamin D level every 12 months --Order dated 03/24/17 got Physical Therapy five (5) times a week for two (2) weeks --Order dated 03/30/17 for [MEDICATION NAME] 20 milligrams one time a day, KCL 10 meq one time a day, and Basic Metabolic Panel in one week due to pedal [MEDICAL CONDITION] The medical record contained no evidence the POA was notified of these medication/treatment changes. An interview with the Director of Nursing, at 9:57 a.m. on 04/19/17, confirmed the medical record contained no evidence Resident #49's POA was notified of the medication/treatment orders. b) Resident #44. Record review found the resident was admitted to the facility on [DATE]. During Stage 1 of the Quality Indicator Survey (QIS), on 04/17/17 at 12:21 p.m., the resident said she is not included in changes about her medication and care at the facility. She said, They tell my daughter, I guess. They must think I am senile. Review of the resident's most recent annual, minimum data set (MDS) with an assessment reference date (ARD) of 03/13/17, found the resident's brief interview for mental status (BIMS). The resident scored a 15 on her BIMS. A score of 15 is the highest score obtainable and indicates the resident is cognitively intact. The MDS noted the resident was able to understand others and make herself understood. The resident had appointed her daughter as her medical power of attorney (MPOA) on 07/06/15. The facility physician determined the resident lacked capacity to make medical decisions on 03/02/17, due to a [DIAGNOSES REDACTED]. On 03/16/17, the physician wrote an order to discontinue her [MEDICATION NAME], current dose, (current dose was 3 mg daily) and change to [MEDICATION NAME] 1 mg daily. A second order, dated 03/16/17, noted to discontinue [MEDICATION NAME] 20 mg and start [MEDICATION NAME] 20 mg every other day in the morning, for 2 weeks, then 20 mg's on Monday and Thursday for 2 weeks, then 20 mg's on Monday for 1 week - then stop the medication. On 04/06/17, the physician started [MEDICATION NAME], 20 mg daily. At 4:09 p.m. on 04/18/17, Employee #43, a Registered Nurse (RN), chief nursing officer, was asked if the changes in medications had been discussed with the resident and/or her daughter, the MPOA? At 8:11 a.m. on 04/19/17, RN #43 provided a consent for use of psychoactive medications, signed by the daughter on 03/15/17. The consent noted the resident is currently receiving [MEDICATION NAME] 1 mg daily. However, the physician's orders [REDACTED]. RN #43 said the facility knew the physician was going to reduce the [MEDICATION NAME] on 03/15/17, so the daughter was advised of the change on 03/16/17. On 04/05/17, the [MEDICATION NAME] was reduced to 0.5 mg daily. On 04/13/17 the Resperdal was again reduced to 0.25 mg daily, with an end date of 04/20/17. At the close of the survey at 11:45 a.m. on 04/19/17, the facility provided no evidence the daughter/resident had been made aware of the gradual dose reductions (GDR) on [MEDICATION NAME] on 04/05/17 and 04/13/17and [MEDICATION NAME] on 03/16/17. There was no evidence of notification the [MEDICATION NAME] was re-started on 04/06/17. c) Resident #8 Resident #8 was admitted to the facility on [DATE]. The resident is her own responsible party. A review of Resident #8's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/10/17, was conducted on 04/18/17 at 9:00 a.m. Section C-Cognitive Patterns of the assessment revealed the resident scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. A score of 15 indicated the resident was cognitively intact at the time of the assessment. An interview with Resident #8, on 04/18/17 at 9:30 a.m., revealed the facility does not notify her when physician's orders [REDACTED]. A review of Resident #8's medical record, on 04/18/17 at 9:45 a.m., revealed the following orders with no resident notification: --physician's orders [REDACTED]. No documentation of resident notification in the medical record. --physician's orders [REDACTED]. Give Tylenol 325 mg at midnight. No documentation of resident notification in the medical record. --physician's orders [REDACTED]. [MEDICATION NAME] 7.5 mg-325 mg 1 tablet po four times a day for pain. No documentation of resident notification in the medical record. An interview with the Administrator on 04/18/17 at 10:05 a.m. revealed she could not provide any documentation the resident was notified of the medication changes.",2020-09-01
200,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2017-04-19,242,D,0,1,HZCX11,"Based on medical record review, resident interview and staff interview, the facility failed to ensure a resident received his desired two (2) showers per week for two (2) of the most recent six (6) weeks. This was evident for one (1) of four (4) residents reviewed for choices. Resident identifier: #18. Facility census: 39. Findings include: a) Resident #18 During an interview with Resident #18, on 04/17/17 at 11:59 a.m., he said he would prefer to have showers three (3) times per week. He stated his belief that staff is aware of this desire, but too busy to honor his choice for three (3) showers per week. He said he does not always get even two (2) per week. Review of the significant change minimum data set (MDS) with assessment reference date (ARD) of 03/03/17, found his brief interview of mental assessment (BIMS) score was fourteen (14) out of a possible score of fifteen (15). A BIMS score of fourteen (14) indicates intact cognition. According to this assessment, the resident required extensive assistance for personal hygiene, and required physical help in part of the bathing activity. Review of the shower records, on 04/18/17 at 9:56 a.m., found this resident was scheduled for two (2) showers per week, on Tuesdays and Fridays. Further review found that of the past six (6) weeks, were two (2) weeks where he received only one (1) shower per week. There was no evidence found that he had refused showers, or that he was out of the facility those weeks. The week of 03/12/17 through 03/18/17, he received only one (1) shower, on 03/17/17. The week of 03/26/17 through 04/01/17, he received only one (1) shower, on 03/31/17. An interview was conducted with licensed practical nurse (LPN) #40, on 04/18/17 at 10:12 a.m. She said she was unaware this resident wanted three (3) showers per week. She said if a resident requested changes in his shower schedule, she tells the assistant director of nursing (ADON) #76, who would then make changes in the shower schedule. An interview was then conducted with nurse #76 on 04/18/17 at 10:29 a.m. She said when residents first come to the facility, they are asked how often they want to receive showers. She said after they have been here awhile, sometimes they might make changes. Upon inquiry as to whether two (2) showers per week were this resident's preference, she replied in the affirmative. She said she was not aware of this resident having asked anyone for three showers per week. She asked him at this time, and he replied that he would like three (3) showers per week. At this time he selected Tuesdays, Thursdays, and Saturdays for his shower days. Nurse #76 said she would change the shower schedule to honor his request. Next, we discussed the recorded showers for the most recent six (6) weeks that are located in the shower book at the nurse's station. Nurse #76 reviewed the shower book, and reviewed computer entries. She found that the only documentation on 03/14/17 and on 03/28/17 pertaining to showers just said not applicable. She could find no evidence that he refused showers on those dates, or that he was out of the facility on those dates. She then went to her office to see if she might find other shower sheets that had not been filed for some reason. The outcome was that she could find no evidence that he received two (2) showers per week during the weeks of 03/12/17 through 03/18/17, and 03/26/17 through 04/01/17.",2020-09-01
201,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2017-04-19,246,D,0,1,HZCX11,"Based on staff interview, resident interview and record review, the facility failed to ensure reasonable accommodations were attempted to allow Resident #2 to be able to have his preference of a shower. This was true for one (1) of three (3) residents reviewed for the care area of choices during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #2. Facility census: 39. Findings include: a) Resident #2 During an interview with the resident, at 12:04 p.m. on 04/17/17, the resident said he would like to be able to take a shower instead of a bed bath. He said he gets his bed baths two times a week but he is unable to shower because the shower chair hurts his hip. Review of the bathing schedule in the facility's point of care computer system, at 10:30 a.m. on 04/18/17, found the resident was coded as receiving, bathing, on every Tuesday and Friday during the months of (MONTH) and April, (YEAR). The point of care system noted the resident prefers a shower. At 10:30 a.m. on 04/18/17, Registered Nurse (RN) #23, the facility consultant for minimum data set (MDS) said the system does not designate a bed bath or a shower, just bathing. At 11:00 a.m. on 04/18/17, Nurse Aide (NA) #59, said she has occasionally bathed the resident. She said the resident wants a bed bath because she believed he had a fear of the shower. She thought the resident had fallen in the shower before. NA #59 said the showers/bed baths are recorded on paper before being put in the computer. The following paper information was provided by NA #59: --03/14/17, bed bath, resident says shower chair hurts him --03/17/17, the resident received a bed bath --03/21/17, bed bath, resident said he wanted to take a shower, then said he did not want one --03/31/17, resident requests bed bath complains of pain with shower. NA #59 was unable to locate all the paper documentation of the resident's bathing schedule. Review of the current care plan found staff should prove a sponge bath when a full bath or shower can not be tolerated. Review of the most recent, quarterly MDS with a assessment reference date (ARD) of 01/27/17, found the resident scored a 15 out of 15 on his brief interview for mental status (BIMS). A score of 15 indicates the resident is cognitively intact, and is the highest score obtainable. At 11:27 a.m. on 04/18/17, the assistant director of nursing (ADON) #76, was interviewed. ADON #76, said, They tell me his hip hurts when he gets a shower. ADON #76 said the facility has two (2) shower chairs, a smaller one and a larger one. She said the facility did not have a shower bed because the showers are so small. She was asked if the facility had tried anything else such as padding the shower chair or any intervention that might make it possible for the resident to shower. She was not aware of any interventions tried by the facility At 11:30 a.m. on 04/18/17, the resident was interviewed with ADON #76 present. The resident again said he wanted to take a shower. He said he slips and slides in the shower chair, causing his hip to hurt. NA #10 was also in the resident's room when the resident was interviewed. NA #10 said, I don't remember when, but the last time I tried to shower him, he never made it through the whole shower because his hip was hurting, he slips in the shower chair. At 9:57 a.m. on 04/19/17, Chief Nursing Officer, RN #43 was interviewed. RN #43 was unable to provide evidence the facility had tried other means to accommodate the resident's preference for showers instead of bed baths.",2020-09-01
202,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2017-04-19,272,D,0,1,HZCX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed an ensure two (2) of three (3) residents reviewed for the care area of dental status had an accurate comprehensive Minimum Data Set (MDS) in the care area of dental status. Resident identifiers: #22 and #18. Facility census: 39. Findings include: a) Resident #22 Observation and review of the most recent, significant change MDS with an assessment reference date (ARD) of 02/28/17, found the facility coded the resident's dental status correctly as the resident has no dentures and no natural teeth. The Care Area Assessment (CAA), which is also a part of the MDS, noted the resident's dental status would not be care planned. The information on the dental CAA asked if dental status is a problem or need. The facility responded with: Potential. The nature of the problem was noted by the facility as, [AGE] year old male admitted from another facility. Resident alert oriented to self and place. Resident has confusion. Resident has behavior issues at times where resident will refuse medications and care at times from staff. Resident ambulates with supervision. Has a history of falls due to weakness. Resident will use a WC (wheelchair) when staff puts him in one. Resident needs staff assist with care, hygiene and ADLS (activities of daily living). Resident does not always participate in activities. Resident eats in dinning room and has to be assisted to dining room from staff. Resident does feed self needs cues at times from staff. Resident is incontinent of bladder at times has had some accidents with incontinence of BM (bowel movements). Resident has not been physical with others. This information did not reference the resident's dental status. At 11:23 a.m. on 04/18/17, the administrator and social services director (SSD) were interviewed regarding the resident's dental status. Both employees were unable to provide evidence the resident's dental status was addressed on the CA[NAME] At 11:23 a.m. on 04/18/17, the SSD provided an oral assessment, dated 01/06/17, noting the resident says he does not want any dentures. She confirmed this information was not present on the CAA for dental status. At 8:20 a.m. on 04/19/17, the above information was discussed with Registered Nurse (RN) #43, the facility's chief nursing officer. RN #43 provided no further information. b) Resident #18 Observation on 04/17/17 at 12:21 p.m., found this resident had four (4) teeth on top, and several teeth on the bottom in the middle. He said he had some cavities that might need fixed, or might need some pulled and a denture made. The medical record was reviewed on 04/18/17. Review of the significant change minimum data set (MDS), with assessment reference date (ARD) 03/03/17, found in the section pertaining to dental, the nurse assessed him as having no teeth (edentulous). A nutritional assessment dated [DATE] addressed his own teeth were in poor condition. A neuroscience consult dated 04/07/17 included as assessment noting dental caries on the smooth surface of a tooth (teeth) penetrating into the pulp. On 04/18/17 at 11:19 a.m., licensed social worker #1 said this resident was to see the dentist in (MONTH) or (MONTH) of this year, but the resident refused. She showed a psychosocial progress note dated 02/10/17 which said that after this resident had a teeth audit, it was recommended that he have dentistry services. However, the resident refused and would not like to be seen by a dentist at this time. On 04/18/17 at 11:19 a.m., the administrator said she would provide a copy of the dental section of the 03/03/17 significant change MDS. On 04/18/2017 at 11:39 a.m., an interview was conducted with assistant director of nursing #76 about the 03/03/17 significant change MDS which said he was edentulous. She said that was in error, as he does have some natural teeth.",2020-09-01
203,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2017-04-19,278,D,0,1,HZCX11,"Based on medical record review and staff interview, the facility failed to ensure the accuracy of a minimum data set for Resident #10 in the area of pressure ulcers. This was evident for one (1) of three residents reviewed for death, and out of sixteen (16) Stage II sampled residents. Resident identifier: #10. Facility census: 39. Findings include: a) Resident #10 The medical record was reviewed on 04/18/17. According to the medical record, this resident developed a Stage II pressure ulcer on his nose on 02/01/17. It was an in-house acquired pressure ulcer, caused by his glasses It was located on a corner of his nose near the left eye. Facility staff asked his medical power of attorney (MPOA) to have his glasses adjusted due to pressure from the nose pieces causing the wound. Facility staff applied foam padding to the nose pieces until the glasses were adjusted. On 02/13/17, facility staff notified the physician and the MPOA of the healed Stage II wound at the corner of his left eye. Review of the 30-day minimum data set (MDS) with assessment reference date (ARD) of 02/02/17, found it correctly assessed the resident as having one (1) Stage II pressure wound. It assessed correctly that the pressure wound was not present on the most recent prior assessment. Review of the 60-day MDS with ARD 03/06/17, found it correctly assessed that he had no current pressure wounds. However, the space was left blank in which to indicate the number of pressure ulcers that were noted on the prior assessment that have now completely closed. During an interview with the corporate MDS registered nurse #23 on 04/18/17 at 1:30 p.m., she said since a Stage II was identified on the 30-day MDS, then it should have been assessed on the 60-day MDS as there having been a previous Stage II wound.",2020-09-01
204,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2017-04-19,280,D,0,1,HZCX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview and facility policy review, the facility failed to afford a resident the right to participate in their care planning. One (1) was not invited to participate in care plan meetings. This practice affected one (1) of two (2) residents reviewed for care planning. Resident identifier: #8. Facility census: 39. Findings include: a) Resident #8 The resident was admitted to the facility on [DATE]. The resident is her own responsible party. A review of Resident #8's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/10/17, was conducted on 04/18/17 at 9:00 a.m. Section C-Cognitive Patterns of the assessment revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) assessment. A score of 15 indicated the resident was cognitively intact at the time of the assessment. An interview with Resident #8 on 04/18/17 at 9:30 a.m., revealed the resident had not been to a care plan meeting since she was admitted to the facility. The resident stated no staff had ever discussed her care plan nor invited her to any care plan meeting. The resident stated she would love to attend a care plan meeting. A review of Resident #8's Care Plan (Target Date 06/30/17), on 04/18/17 at 9:40 a.m., revealed the following intervention: Promote participation in care planning process-Invite to team conference. Further review of the medical record, on 04/18/17 at 9:55 a.m., revealed the facility had conducted a care plan meeting for Resident #8 on 08/18/16. A progress note dated 08/21/16 stated Family did not attend plan of care meeting on 08/18/16. There was no documentation that the resident attended or was invited to the meeting. No documentation of any further care plan meetings or evidence of any invitations to the resident was found in the record. An interview with the Administrator, on 04/18/17 at 10:10 a.m., revealed she could not provide any documentation Resident #8 had ever been invited to or attended a care plan meeting. The Administrator stated she had no further documentation to show another care plan meeting had been conducted for Resident #8 since 08/18/16. A review of the facility's policy titled Resident/Family Participation-Assessment/Care Plans, with a revision date of (MONTH) 2007, revealed Each resident and his/her family members are encouraged to participate in the development of the resident's comprehensive assessment and care plan.",2020-09-01
205,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2017-04-19,312,D,0,1,HZCX11,"Based on observation, record review, staff interview and resident interview, the facility failed to provide activities of daily living (ADL) care to Resident #39 who was unable to perform the care herself. Resident #39 was observed with multiple long hairs on her chin and indicated she needed the staff to remove them for her. This was true for one (1) of four (4) residents reviewed for the care area of ADL's during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #39. Facility census: 39. Findings include: a) Resident #39 An observation of Resident #39, during Stage 1 of the QIS, at 12:09 p.m. on 04/17/17, found several long hairs on her chin. A review of Resident #39's medical record, at 8:00 a.m. on 04/19/17, found the resident required extensive assistance of staff to carry out her personal hygiene ADL's. An additional observation and interview with Resident #39, at 8:45 a.m. on 04/19/17, with the Assistant Director of Nursing (ADON) and Social Service Director (SSD) present found the hair was still present on her chin. When asked if she would like to have the hair removed from her chin Resident #39 stated, Yes they are getting long and they have to remove them for me. The ADON agreed the staff needed to remove the hair from Resident #39's chin and instructed her assigned Nurse Aide to remove the hair.",2020-09-01
206,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2017-04-19,505,D,0,1,HZCX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the physician was promptly notified of an abnormal laboratory value for one (1) of five (5) resident's reviewed for the care area of unnecessary medications. The physician is to be notified promptly in order for appropriate action to be taken if indicated for the resident's care. Resident identifier: #16 Facility census: 39. Findings include: a) Resident #16 On 01/09/17, the physician ordered the following laboratory values: --Lipid profile, --[MEDICAL CONDITION] profile, and --Comprehensive metabolic panel (CMP) According to the laboratory report, the results of the testing were available to the facility on [DATE]. On 01/12/17, the physician was notified of the laboratory values. The physician provided orders to discontinue the resident's [MEDICATION NAME] and obtain a BMP (Basic Metabolic Panel) in the a.m. The results of the 01/09/17, CMP noted the following abnormal values: --BUN (blood urea nitrogen) was high, 67, (Normal range is 6-35) --Creatinine was high- 2.3, (Normal range is 0.5 - 1.7) --B/C (BUN to Creatinine) ratio was high- 29.1 (Normal range was 7-18) --Sodium was high- 144, (Normal range is 136-142) --GFR ( glomerular filtration rate-measures the level of kidney function to determine your stage of kidney disease) was low - 19.83, (Normal range is greater than 60) On 01/13/17, a basic metabolic panel (BMP) was obtained as ordered. The results of the BMP are as follows: --Sodium was high- 143, (Normal range is 136 - 142) --Potassium was high - 5.6, (Normal range is 2.5 - 5.3) --BUN was high- 72, (Normal range is 6 - 35) --Creatinine was high - 1.8, (Normal range is 0.5 - 1.7) --GFR was low - 26.6, (Normal range is greater than 60) At 3:04 p.m. on 04/18/17, the Registered Nurse (RN) minimum data set (MDS) consultant was interviewed. She was unable to provide information the resident's physician was ever notified of the second laboratory values obtained on 01/13/17 and available to the facility on [DATE]. At 8:05 a.m. on 04/19/17, the Chief Nursing Officer/Registered Nurse (RN) #43 was also unable to provide verification the resident's physician was aware of the abnormal laboratory values obtained on 01/09/17 in a prompt manner. RN #43 did provide a copy of a nurses note on 01/16/17 at 10:35, which noted: Resident's labs reviewed and adjusted r/t (related to) new lab regimen. The first lab was obtained on 01/09/17 and was available to the facility on [DATE]. This lab was not reviewed by the physician until 01/12/17. The second laboratory value was obtained on 01/13/17. The copy of the laboratory report was noted as being obtained on 04/18/17, the date of surveyor intervention.",2020-09-01
207,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2017-04-19,507,D,0,1,HZCX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a copy of an abnormal laboratory value was available in the medical record for physician review. This was true for one (1) of five (5) resident's reviewed fro the care area of unnecessary medications during Stage 2, of the Quality Indicator Survey (QIS). Resident identifier: #16. Facility census: 39. Findings include: a) Resident #16 Medical record review on 04/18/17, at 2:00 p.m. found the resident's physician ordered a BMP (Basic Metabolic Panel) to be completed on the morning of 01/13/17. At 3:04 p.m. on 04/18/17, the Registered Nurse (RN) minimum data set (MDS) consultant, #23 was interviewed. She was unable to provide a copy of the BMP, ordered on [DATE], by the resident's physician. A copy of the laboratory value was provided to the surveyor later in the day by RN #23. The laboratory report noted the BMP was collected on 01/13/17 at 5:16 p.m. The date received by the laboratory was 01/13/17. The date the results of BMP were provided was 04/18/17 At 8:05 a.m. on 04/19/17, the Registered Nurse , chief nursing officer, #43, was notified of the above findings. She confirmed the facility was unable to find the laboratory value from 01/13/17. The facility had to contact the laboratory to obtain the test on 04/18/17.",2020-09-01
208,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2017-04-19,514,E,0,1,HZCX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) Resident #55 Review of the medical record found the resident's physician completed a on site visit to the resident on 01/20/17. A progress note was completed for this visit by the physician. The physician noted, .The patient also presented with diabetes mellitus. It is described as impaired glucose tolerance, chronic and stable. The symptom started onset as an adult. The complaint is mild The symptom is alleviated by medication and diet. Review of the resident's Medication Administration Record [REDACTED]. At 8:31 a.m. on 04/19/17, the Registered Nurse (RN), chief nursing officer, #43, confirmed the MAR indicated [REDACTED]. She said she would call the physician in regards to the 01/20/17 visit. At 10:11 a.m. on 04/19/17, RN #43 said she had talked to the physician by telephone. The physician told RN #43, her notes were in a template and she just made a mistake in her dictation, the resident was not receiving any medications to treat diabetes mellitus. RN #43 provided a copy of a corrected physician's visit noting the following, .The patient also presented with diabetes mellitus. It is described as impaired glucose tolerance, chronic and stable. The symptom started onset as an adult. The complaint is mild. Alleviating factor diet . Based on medical record review and staff interview, the facility failed to maintain a complete and accurate medical record for two (2) of sixteen (16) Stage II sampled residents. The facility did not record monthly fasting blood sugar results for Resident #15. The facility did not ensure the accuracy of the monthly physician progress notes [REDACTED].#55's blood sugars and/or medical status related to his diabetes mellitus. Resident identifiers: #15 and #55. Facility census: 39. Findings include: a) Resident #15 The medical record was reviewed on 04/18/17. On 01/09/17, the physician discontinued the order for daily blood sugars four (4) times daily, along with the sliding scale insulin administration. The blood sugar assessments were changed instead to a fasting blood sugar (FBS) once per month. Review of the medication administration records (MAR) for January, February, and (MONTH) (YEAR) found that nurses initialed on the MARs they had obtained a FBS on 01/18/17, 02/17/17, and 03/19/17. However, the nurses did not document the results of the FBS assessments on the MARs or in the nurse progress notes. An interview was completed with Registered Nurse consultant #43 on 04/19/17 at 9:12 a.m. She said she was unable to find any recorded FBS results on the MARs or progress notes for the dates of 01/18/17, 02/17/17, or 03/19/17. She agreed staff initialed they performed the FBS checks on those dates. She stated her opinion staff would have notified the physician had any of the results been abnormal, so they must have been normal. An interview was completed with the administrator on 04/19/17 at 9:28 a.m. She said the physician's orders [REDACTED]. She stated her opinion that had the FBS results been out of parameters, then the nurses would have notified the physician. She explained the monthly FBS is due to a pharmacy regulation related to antipsychotic medication use, but the facility is using Hemoglobin A1C blood tests every three (3) months to assess her overall blood sugar controls. She provided a lab report dated 01/19/17 where the A1C was 7.3, whereas the previous one had been 6.8. The serum glucose from the lab on that date was 118. She said the lab was in the facility this morning and drew another A1C.",2020-09-01
209,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2018-05-03,656,D,0,1,GLW711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and staff interview, the facility failed to ensure person-centered comprehensive care plan developed and implemented to meet the resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for two (2) of seventeen (17) residents reviewed. Resident #4's care plan failed to address [MEDICAL CONDITIONS] and contractures. Additionally, Resident #8's care plan failed to address the use of an anticoagulant. Resident identifiers: #4 and #8. Facility census: 37. Findings included: a) Resident #4 Review of Resident #4's medical record began on 05/01/18 at 11:15 a.m., found the resident was admitted [DATE]. [DIAGNOSES REDACTED]. Review of Resident #4's physician progress notes [REDACTED]. Observation of Resident #4 on 04/30/18 at 11:30 a.m., found resident appeared to have contractures of upper and lower extremities. This observation was confirmed by the Occupational Therapist. Interview with the Director of Nursing (DON) on 05/02/18 at 11:15 a.m., she confirmed after review of the comprehensive care plan, the care plan did not include [MEDICAL CONDITIONS] and multiple contractures of upper and lower extremities. b) Resident #8 Resident #8 had an order for [REDACTED]. Resident #8 also had an order to Monitor for signs/symptoms of bruising/bleeding/skin alterations, every shift, due to [MEDICATION NAME] therapy. Resident #8's Medication Administration Record [REDACTED]. However, Resident #8's comprehensive care plan did not have a focus related to the medication [MEDICATION NAME]. During an interview on 05/01/18 at 1:29 PM, the Director of Nursing (DoN) agreed Resident #8's comprehensive care plan did not have a focus related to the medication [MEDICATION NAME].",2020-09-01
210,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2018-05-03,657,D,0,1,GLW711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to revise the comprehensive care plan for three (3) of seventeen (17) resident's comprehensive care plans reviewed. The facility failed to revise the comprehensive care plan for Resident #21 in the area of skin integrity when he developed an actual skin impairment. The facility failed to revise the comprehensive care plan for Resident #30 in the area of an overall decline and hospice involvement. The facility also failed to revise the comprehensive care plan for Resident #26 when incontinence associated [MEDICAL CONDITION] and skin tears resolved. Resident indicators: #21, #30, #26. Facility Census: 37. Findings included: a) Resident#21 Resident #21 had an order for [REDACTED].>On [DATE], the weekly Skin Observation Tool documented Resident has redden (sic) area to the area behind top of left ear d/t (due to) oxygen hose, which is being treated. No other skin tears or bruising noted. On [DATE] at 10:39 AM, Licensed Practical Nurse (LPN) #81 was observed performing care to Resident #21. The top of Resident #21's left ear was observed to be reddened. LPN #81 inserted new foam protectors on Resident #21's oxygen tubing to protect the top of his ear. LPN #81 stated the foam protectors needed to be reapplied periodically because Resident #81 removed them. She also stated Hydrogel was being applied to the reddened area on the top of Resident #21's left ear. Resident #21's comprehensive care plan contained the focus, The resident has potential for impairment to skin integrity r/t (related to) fragile skin. However, the comprehensive care plan did not contain a focus or interventions related to the reddened area on Resident #21's left ear. During an interview on [DATE] at 12:32 PM, the Director of Nursing (DoN) agreed Resident #21's comprehensive care plan did not contain a focus related to his actual skin impairment or the specific interventions being performed for the condition. b) Resident #30 Review of Resident #30's closed medical records [REDACTED]. The [DIAGNOSES REDACTED]. Resident # 30 experienced an overall decline and was placed on Hospice care on [DATE] due to her poor prognosis. Resident #30 expired at the facility on [DATE]. Review of Resident #30's comprehensive care plan dated [DATE], was not revised when the resident experienced an overall decline which required hospice care. Interview with the Director of Nursing (DON) on [DATE] at 2:15 p.m confirmed the care plan was not revised after Resident #30 experienced an overall decline which resulted in hospice care. c) Resident #26 Resident #26's medical record review began, on [DATE] at 1:10 p.m., revealed no skin impairment (skin tears and incontinence associated [MEDICAL CONDITION] (IAD)). Additionally, she was care planned for skin tear to right thigh dated [DATE]. Review of Resident #26's compressive care plan found the resident was care planned for IAD dated [DATE]. Additionally, the resident was care planned for skin tear to right thigh dated [DATE]. Both IAD and skin tear had resolved over three (3) weeks ago. Interview with the Director of Nursing (DON) on [DATE] at 2:15 p.m confirmed the care plan was not revised after Resident #26's skin impairments (IAD and skin tear) had resolved. She confirmed it should have been revised.",2020-09-01
211,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2018-05-03,761,D,0,1,GLW711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation amd staff interview, the facility failed to store pharmaceuticals in accordance with currently accepted standards of professional principles. The multi-dose bottle of [MEDICATION NAME] stored in the medication cart on the facility's second floor was not dated when it was opened. This was discovered during the facility task of medication adminstration and had the potential to affect all residents on the second floor who were prescribed [MEDICATION NAME]. Facility census: 37. Findings included: a) Facility task - medication pass On 05/02/18 at 7:49 AM, the morning medication pass was observed by Registered Nurse (RN) #28. During medication administration, a multi-dose bottle of [MEDICATION NAME], a laxative, was removed from a drawer in the medication cart and a dose was poured into a glass for administration to a resident. The [MEDICATION NAME] bottle had been previously opened. However, the [MEDICATION NAME] bottle was not dated when it was opened. RN #28 agreed the multi-dose bottle of [MEDICATION NAME] was not dated when it was opened. On 05/02/18 at 8:55 AM, the Director of Nursing (DoN) was notified the multi-dose bottle of [MEDICATION NAME] stored in the medication cart on the second floor was not dated when opened. The DoN stated, We'll fix it.",2020-09-01
219,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2019-04-03,550,D,0,1,P29Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to ensure dignity during medication administration for Residents' #84 and #38. This was a random opportunity for discovery. Resident identifiers: #38 and #84. Facility census: 97. Findings included: a) Resident #38 At 11:48 AM on 04/01/19, Licensed Practical Nurse (LPN) #15, was observed obtaining the resident's blood sugar in the hallway, opposite the dining room on the Reflections unit. Record review found a physician's orders [REDACTED]. The resident's last full minimum data set (MDS), an annual, with an assessment reference date (ARD) of 11/06/18 coded the resident as having a score of 3 on the brief interview for mental status (BIMS). A score of 3 indicates the resident has severely impaired cognition. The resident would be unable to say if she preferred her blood sugar to be obtained in the hallway. On 04/01/19 at 2:13 PM, LPN #15 said she had just attended an in service about not giving medications while residents are in the dining room eating but nothing was said about obtaining blood sugars in the hallway. She was unaware she shouldn't obtain blood sugars in the hallway. On 04/02/19 at 1:02 PM, the above observation was discussed with the administrator. No further information was received before the close of the survey on 04/03/19 at 5:00 PM. b) Resident #84 At 11:44 AM on 04/01/19, Resident #84 was observed in the hallway, across from the dining room on the Reflections Unit, with LPN #15 and Resident #34. LPN #15 raised the resident's shirt and was attempting to inject insulin into the abdomen of Resident #84. The resident became combative. She was waving her hands and trying to push away the insulin. The Resident was making growling noises. LPN #15, said to the surveyor, Well I guess I will try this later. Record review found Resident #84's last full minimum data set (MDS), a significant change MDS, with a reference assessment date (ARD) of 12/11/18 coded the resident as having memory problems both long and short term. Daily decision making was severely impaired. On 04/01/19 at 2:13 PM, LPN #15 said she had just attended an in service about not giving medications while residents are in the dining room eating but nothing was said about obtaining blood sugars in the hallway. She said she was unaware she shouldn't give injections in the hallway. LPN #15 said she later gave the injection to the resident in the hallway, after the resident calmed down. Record review found Resident #84 has a physician's orders [REDACTED]. On 04/02/19 at 1:02 PM, the above observation was discussed with the administrator. The administrator had no comment. At 1:30 PM on 04/02/19, the administrator provided a copy of the medication administration audit report noting the resident received the [MEDICATION NAME] at 12:04 PM on 04/01/19.",2020-09-01
220,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2019-04-03,558,D,0,1,P29Y11,"Based on observation and resident/staff interviews, the facility failed to keep the call light easily accessible for Resident #21. This was a random opportunity for discovery. Facility census: 97 Findings included: a) On 04/03/119 it was observed at 8:30 a.m. the call light was down in the floor between the bed and a nightstand as it had been on the day of tour 04/01/19 . Interview with the administrator immediately after this observation revealed the resident does keep the call bell on the floor in that position, but they could get her a cow bell or some kind of bell that may work to provide her with some way of communication with staff should she need help.",2020-09-01
221,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2019-04-03,656,E,0,1,P29Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to implement the care plans of two (2) of twenty-one (21) Resident's whose care plans were reviewed. For Resident #38, the care plan was not implemented for fall prevention. Resident #48's, the care plan was not implemented for care of a [MEDICAL TREATMENT] resident. Resident identifiers: #38 and #48. Facility census: 97. Findings included: a) Resident #38 Review of the resident's current care plan found the following problem: --Resident has a history of falls. Poor balance, unsteady gait. The goal associated with the problem: --Resident will not receive any injuries from falls through next review. Interventions included: --Break away lap buddy while in wheelchair. Observation of the resident at 11:44 AM on 04/01/19, found the Resident was trying to remove her break away lap buddy. ( A lap buddy is an inflatable pillow that fits into the frame of the wheelchair and is meant to gently remind the occupant to ask for help before getting up.) She was pulling and tugging at the edges of the lap buddy. The Resident tried numerous times to stand up in her wheelchair, causing her chair alarm to engage. At one point the lap buddy released, and the resident began to stand up. A nursing assistant intervened and calmed the resident before fastening the lap buddy back into place. Review of the resident's medical record found a physician's orders [REDACTED]. At approximately 12:15 PM on 04/01/19, the breakaway lap buddy was removed from the wheelchair during meal time. The resident appeared calm. She stayed in her wheelchair, seated at the table and was not trying to stand up during her meal. At 2:26 PM on 04/01/19, the resident continued to be in the dining room area, in her wheelchair without her break away lap buddy. Licensed Practical Nurse (LPN) #15 was asked why the resident did not have her lap buddy. LPN #15 said the resident was actually better without the lap buddy. She seems more calmer without it, so we take it off sometimes. Observation found the resident was calm. She was setting in her wheelchair and was not trying to stand up. The alarm in the wheelchair was not sounding. At 1:10 on 04/02/19, the above observations were discussed with the administrator. The administrator said she would have the physician write a new order so the resident would not have to have the lap buddy in place at all times as indicated by the care plan and the current physician's orders [REDACTED].>On 04/02/19 a new order was written for: Break away lap buddy while in wheelchair, as needed. b) Resident #48 During a review of physician order [REDACTED]. --No blood pressures (BP) or blood draws on right arm due to fistula in the right arm for [MEDICAL TREATMENT] access. --Care plan also directs no BP or blood draws on right arm due to fistula for [MEDICAL TREATMENT] access. Electronic chart under the vital signs tab were as follows: --03/26/2019 at 10:31 AM BP was 156/93 mmHg - no indication which arm BP was taken --03/21/2019 at 09:53 AM was 169/97 mmHg - BP taken on right arm --03/20/2019 at 4:28 PM was 159/95 mmHg - BP taken on right arm --03/19/2019 at 10:40 AM was 144/89 mmHg - BP taken on right arm --03/18/2019 at 3:25 PM was 133/84 mmHg Other - no indication which arm BP was taken --03/15/2019 at 3:18 PM was 128/79 mmHg - BP taken on right arm --03/9/2019 at 12:23 PM was 136/85 mmHg - BP taken on right arm The profession standard of practice is to avoid any kind of pressure on the arm with a fistula, as it can lead to [MEDICAL CONDITION] (a blood clot inside of the blood vessel). During an interview on 04/02/19 at 1:24 PM, DoN was asked about the documentation of getting B/P in the right arm. She said that it was done, half hazarder and the Nurse Aides (NA) do them and the nurses enter them in the chart. She agreed that they should have and said that she is not saying it was right. She also agreed that there is no way to know if the B/P was or was not taken in the right arm and all we must go by is the documentation. She agreed that the according to the documentation the staff did not follow the care plan.",2020-09-01
222,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2019-04-03,657,E,0,1,P29Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation, the facility failed to revise the care plans for four (4) of 21 resident's reviewed when the residents treatment, preferences and needs of the resident changed in response to current interventions. Resident's #38 and #84's care plans were not revised to reflect the current activity interests. Resident #21's care plan was not revised to reflect a change in the use of the call light. Resident #17's care plan was not revised to reflect removal of a Peripherally Inserted Central Catheter (PICC) Line. Resident identifiers: #38, #84, #21, and #17. Facility census: 97. Findings included: a) Resident #38 Resident #38 resides on the Reflections Unit of the facility. To enter or exit the unit a code is required to be entered on a key pad. The unit is not a certified dementia unit but can house up to 20 residents at a time. The residents on this unit have cognitive loss. Resident #38 scored a 3 on her brief interview for mental status (BIMS). A score of 3 indicates the resident is severely cognitively impaired. Review of the resident's current plan of care found the resident was care planned for the following focus problem: --Resident has no interest in out of room activities. She at times prefers her own room, in her bed sleeping. The goal associated with the problem is: --Resident will attend 1 out of room activity per week through next review. Interventions included: --Provide in room activity supplies as needed. --Resident enjoys taking care of baby doll on occasion. --Resident has stated that in the past she enjoyed playing board games/cards with her children, doing crafts/sewing, gardening/canning, helping others, reading, shopping. --Resident has stated that she enjoys watching TV/news and weather, listening to country music/radio, playing the harmonica, singing, being outdoors weather permitting, talking to others, church, being active. Observation of the resident on 04/01/19 at 11:44 AM, 12:05 PM, 1:48 PM, 2:04 PM, 2:13 PM, 2:31 PM, and 3:16 PM on 04/01/19 found the resident was out of her room either in the dining room or the hallway leading to the dining room on the Reflections unit. Observation on 04/02/19 the resident was again in the hallways or the dining area at 10:18 AM and 12:20 PM. On 04/02/19 at 2:20 PM, the resident's nursing assistants, NA #148 and NA #130 said the resident isn't in her room unless she is sleeping at night time. Both said the resident has a short attention span and has difficulty staying focus. NA #148 said the resident likes music and likes to yodel. She likes her doll baby, she likes food. We have sensory stimulation activities, but she will look at them for a short period and then she is done. She likes to be pushed around in her wheelchair, but she tires of that also. She likes attention but needs a constant change in activities. Both NA's said the resident likes to sleep in until around 9:00 AM, and then she is up for the day. Neither staff member felt the resident preferred to stay in her own room. Both employees knew the resident was a fall risk and needed constant supervision. Both employees felt she would not be safe if left alone in her room where supervision would be more difficult. On 04/02/19 at 2:30 PM, the activity assistant (AA) #121, assigned to the Reflections Unit, was unaware the resident has no interest in out of room activities. AA #21 could provide no evidence the resident was provided activities in her own room. AA said the resident was out of her room daily, in a common area, the lounge, hallway, or the dining room. On 04/02/19 at 3:20 PM, the activity director (AD) #55, was asked to make observations of Resident #38 on the Reflections unit. The resident was up in the dining area. AD was unable to provide evidence the resident has no interest in out of room activities. The AD provided copies of the residents attendance at activities: --On 04/01/19 the resident attended a pre meal activity and current events. --Review of the activity's participation log found similar attendance at activities through the month of (MONTH) 2019. --The resident was not provided any in-room activities. All activities attended were out of room in a common area. AD #55 said she would revise the resident's care plan. b) Resident #84 Resident #84 resides on the Reflections Unit of the facility. To enter or exit the unit a code is required to be entered on a key pad. The unit is not a certified dementia unit but can house up to 20 residents at a time. The residents on this unit have cognitive loss. Resident #84's minimum data set (MDS) with a assessment reference date (ARD) of 12/11/18 coded the residents as being unable to participate in a brief interview for mental status (BIMS) due to her severe cognitive loss. Observation of the resident on 04/01/19 at 11:44 AM, 12:05 PM, 1:48 PM, 2:04 PM, 2:13 PM, 2:31 PM, and 3:16 PM on 04/01/19 found the resident was out of her room either in the dining room or the hallway leading to the dining room on the Reflections unit. The resident frequently rolled up and down the hallway in her wheelchair. Observation on 04/02/19 the resident was again in the hallways or the dining area at 10:18 AM and 12:20 PM. Review of the Resident's current care plan found the problem: --Resident shows very little interest in out of room activities most days. She prefers to be in her own room: in bed at times sleeping. She is self directed in her room. Interventions included: --Provide in room activity supplies as needed. --Provide activity calendar. --Resident in the past enjoyed playing cards/word games crafts, keeping up with current events/news, exercising/walking, gardening, helping others what she can she states, socializing, reading going to church, talking with others, shopping only what she needs she states, being outdoors, and watching TV/movies. --Resident in the past enjoyed walking around the facility with staff most days. --Resident likes to sleep in most mornings, and takes naps throughout the day. On 04/02/19 at 2:48 PM, the resident's nursing assistants, NA #148 and NA #130 said the resident isn't in her room unless she is sleeping at night. NA #148 said the resident is frequently up during the night time. Both said the resident has a short attention span and has difficulty staying focus. NA #148 said Resident #84 is never in her room. She only goes in to get changed during the day. She beats me out of the room, you can't even get her in the room for toileting. NA's #148 and #130 said the resident doesn't nap during the day. On 04/02/19 at 2:50 PM, the activity assistant (AA) #121, assigned to the Reflections Unit, was unaware the resident has no interest in out of room activities. AA #21 could provide no evidence the resident was provided activities in her own room. AA said the resident was out of her room daily, in a common area, the lounge, hallway, or the dining room. AA #121 said the resident participates in out of room activities daily. Review of the Resident's activity's participation sheets found no evidence of any in room activities. The resident attended out of room activities during the month of (MONTH) and (MONTH) 2019. On 04/02/19 at 3:20 PM, the activity director (AD) #55, was asked to make observations of Resident #84 on the Reflections unit. The resident was up in the dining area. AD was unable to provide evidence the resident was provided any in room activities. AD #55 said that was the residents past preference and she will update the care plan to include current interests. d) Resident # 17 The facility failed to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team for Resident #17. Specifically, the facility failed to update the care plan when the resident's PICC (Peripherally Inserted Central Catheter) line was removed. On 04/02/19, review of care plan revealed an active ongiong focus area initiated on 02/19/19 of: Resident has PICC line - potential for complications. Goal for care area stated: resident will be free of complications related to PICC line through next review with target date of 04/15/19. Interventions initiated on 02/19/19 included: change PICC line dressing as ordered, flush PICC line as ordered, observe for signs and symptoms of infection including but not limited to: redness, [MEDICAL CONDITION], pain or drainage at PICC line site, fever, mental status change, etc. Medical record review on 04/02/19 at 3:58 PM revealed progress note dated 02/23/19 stating Resident was sent to local emergency department due to PICC line bleeding. Orders for PICC line care were discontinued on the treatment administration record when resident returned from hospital on [DATE]. During an interview on 04/03/19 at 10:27 AM, Family Nurse Practitioner (FNP) #49 confirmed Resident #17 did not have a PICC line. FNP #49 stated the PICC line had been removed when the Resident returned to the facility on [DATE] from the hospital. c) Resident #21 Resident #21 does not like the call bell and keeps in on the floor near the night stand. Review of the care plan said to encourage resident to use the call bell due to frequent falls in the past. An alternative method which may be acceptable for the resident to use when calling for assistance was not explored or identified by facility staff. Discussion with the resident on 04/01/19 in the afternoon verified she does not like the call bell and keeps it down in the floor out of the way. This was noted again on observtions on 04/03/19. The administrator at this time said the staff realized she liked to do this but there had been no alternative method of calling for assistance put on place or care planned for.",2020-09-01
223,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2019-04-03,684,E,0,1,P29Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to provide care in accordance with the goals for care and professional standards of practice that will meet each resident's needs. This was in regard to medications being administered more than an hour past the time it was due and failing to provide peri care for a resident with incontinence.This was a random opportunity for discovery. Resident identifiers: #14, #62, #11 and #16. Facility census: 97. Findings included: a) Failure to administrator medications within an acceptable time frame During an observation on 04/02/19 at 11:10 AM, Registered Nurse (RN) #135 was carrying a cup of pills in the hallway. She was asked if she had more medications to pass. She said yes, it was noted that all of the residents on her computer screen was in red (indicating the medication was given late) she was asked about the medications being late. She began by saying that this is only her second day passing medication and it she must try to match the pictures of the residents in order to give the medication. So that takes a while to do and it is different than when she worked in an Intensive Care Unit (ICU). She went on to said that she does not check them off in the computer as she administrated the medication, she said, I check it off on my paper then later when I get to set down, I adjust the times given or I would be even later. She was asked if she still had any medications left to give that was supposed to be given at 9:00 AM? She said yes. Administrator was informed at 04/02/19 11:19 AM, about what this nurse was doing. She stated that it was not their practice to document after all the medications were given but as they were given. She also said that RN #135 has been working at the facility for about two (2) months. She stated that she cannot have that, and she was going to end this RN's contract and have someone else take over. She was asked for a medication audit report for the residents that this nurse was caring for. The report titled, Medication Audit Report was as follows: a-1) Resident #14 All of these mediations were scheduled for 9:00 AM and was administrated at 11:43 AM, making them one hour and 43 minutes late. The professional standard is one hour before and one hour after the scheduled time. -Calcium-Vitamin D3 -[MEDICATION NAME] (for history of [MEDICAL CONDITION] embolism) -[MEDICATION NAME] Acid -Ferrosol -[MEDICATION NAME] (for hypertension) -Multivital -Potassium Chloride -[MEDICATION NAME] (for [MEDICAL CONDITION]) -Aspirin -Apremilast (for Psoriasis) -[MEDICATION NAME] -[MEDICATION NAME] (for GERD) -[MEDICATION NAME] (for allergies [REDACTED].>-Eliquis (for history of [MEDICAL CONDITION] embolism) -Cranberry a-2) Resident #62 -[MEDICATION NAME] -[MEDICATION NAME] (for reflux) -[MEDICATION NAME] (for hypertension) -[MEDICATION NAME] (for hypertension) -Memantine (for dementia) -[MEDICATION NAME] Sodium -Losartan Potassium (for hypertension) -[MEDICATION NAME] (for over active bladder) -Vitamin D3 -[MEDICATION NAME] (for depression) -Potassium (for [DIAGNOSES REDACTED]) a-3) Resident #11 -[MEDICATION NAME] (for hypertension) -[MEDICATION NAME] (for hypertension) -[MEDICATION NAME] (nasal drainage) -[MEDICATION NAME] (for reflux) -[MEDICATION NAME] Acid (for convulsions) -Magnesium [MEDICATION NAME] (for constipation) -[MEDICATION NAME] ([MEDICAL CONDITION]) -2 cal -[MEDICATION NAME] (for allergies [REDACTED].>-Tylenol (for pain) -[MEDICATION NAME] (for muscle pain) -Docu Soft (for constipation) -[MEDICATION NAME] b) Resident #16 Random opportunity for discovery revealed the facility failed to provide perineal care (washing genitalia and surrounding area) to Resident #16 in accordance with professional standards of care. On 04/03/19 at 1:19 PM Nurse Aide (NA) #36 and NA #141 were observed as they provided perineal care for Resident #16. NA #36 presented to bedside with gloves donned (to put on gloves), with one wet soapy wash cloth, one wet wash cloth without soap, one dry wash cloth, and no wash basin. NA #36 draped all wash clothes across top of left upper bed rail and positioned Resident supine (on back), unfastened Resident's brief and folded the front of brief down and tucked it under the Residents buttock. Resident's brief was visibly soiled with a bowel movement and urine. NA #36 proceeded with perineal care by separating Resident's legs that were bent at the knees and very stiff (due to contractures) and made one wipe down the front of the perineum across the labia with the soapy wash cloth. NA #141 then assisted NA #36 to turn resident to her right side and NA #36 folded soiled soapy wash cloth and wiped one time up the Resident's buttock. NA #36 then wiped the perineal area one time from front to back bewteen the buttocks with the wash cloth that was said to be a rinse wash cloth containing only water, then wiped one time between the buttocks with the dry wash cloth. NA #36 then pulled soiled brief out from under resident, rolled brief up and laid brief on top of trash bag on foot of bed with soiled washcloths on top. Without removing soiled gloves, NA #36 then walked over to resident's dresser, opened top drawer with soiled gloves on, shuffled through clothing and obtained heel protectors from drawer and placed them on resident. NA #36 then separated soiled brief from soiled washcloths, removed soiled glove from right hand only, and placed items in separate trash bags. While continuing to wear soiled glove on left hand, NA# 36 covered resident up with sheet with both hands, lowered bed with right ungloved hand, and placed call bell on resident's chest with left hand. NA#36 then removed soiled glove from her left hand and handed trash bags to NA# 141 for disposal, and went to bathroom and washed hands. Review of Perineal Care policy with revise date of 10/16/16 included the following instructions for perineal care for a female resident without an indwelling catheter: Wet wash cloth and apply soap or skin cleansing agent. Wash perineal area, wiping from to back. Separate labia and wash area downward from front to back. Continue to wash perineum moving from inside outward to and including thighs, alternating from side to side, and using downward [MEDICAL CONDITION]. Do not use same washcloth or water to clean the urethra or labia. Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. Gently dry perineum. Instruct or assist the resident to turn on her side with her top leg slightly bent, if able. Rinse wash cloth and apply skin cleansing agent. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Do not reuse the same wash cloth or water to clean the labia. Rinse thoroughly. Dry area thoroughly. Discard disposable items into designated containers. Remove gloves and discard into container. Wash and dry your hands thoroughly. Reposition the bed covers. Make resident comfortable. Gently dry perineum. Review of employee record revealed NA #36 attended in-service training on 01/15/19 for education of perineal care and hand hygiene and successfully completed staff competencies for female incontinence care (perineal care) in bed and proper hand washing technique observed by Director of Staff Development Registered Nurse (RN) #20. During an Interview on 04/03/19 at 2:43 PM, Director of Staff Development Registered Nurse #20 verified NA# 36 was in attendance for in-service training on 01/15/19 for perineal care of residents, and NA #36 demonstrated competency in care area by successfully completing skills evaluation check off.",2020-09-01
224,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2019-04-03,686,D,0,1,P29Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, and to prevent infection in a pressure ulcer. There was a delay in treatment for [REDACTED]. This was true for One (1) of two (2) reviewed for care of pressure ulcers. Resident identifier: #6. Facility census: 97. Findings included: a) Resident #6 A review of Resident #6's medical record at 8:27 a.m. 04/02/19 found a wound culture which was collected on 10/23/18. The results of this wound culture was released to the facility on [DATE] and indicated the resident had staphylococcus in the wound. A nurse wrote on the lab result that it was noted on 10/28/18. The certified nurse practitioner (CFNP) did not sign the lab until 10/29/18 at which time she ordered [MEDICATION NAME] 500 mg every day for 10 days. Review of the Medication Administration Record [REDACTED]. An interview with the Nursing Home Administrator at 8:00 a.m. on 04/03/19 confirmed Resident #6 was not started on her antibiotic for the wound infection until 10/30/18. She stated, I don't know where the delay came from.",2020-09-01
225,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2019-04-03,758,D,0,1,P29Y11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #98's medication regimen was free from unnecessary [MEDICAL CONDITION] medications. She received two doses of as needed [MEDICATION NAME] prior to the facility implementing non pharmacological interventions. This was true for One (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #98. Facility census: 97. Findings include: a) Resident #98 A review of Resident #98's Medication Administration Record [REDACTED].m Further review of the medical record found no evidence the facility implemented any non pharmacological interventions prior to the administration of this medication. An interview with the Nursing Home Administrator at 11:06 a.m. on 04/03/19 confirmed there was not any non pharmacological interventions implemented prior to the administration of the as needed [MEDICATION NAME].,2020-09-01
226,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2019-04-03,761,E,0,1,P29Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and staff interview the facility failed to label multi-use vials and/or pens of insulin (used to treat elevated level of blood sugars in people with diabetes) with the initial date it was opened and/or accessed. This failed practice was not in accordance with currently accepted professional principles. This had the potential to effect the potency and effectiveness of the medications. Resident identifiers: #24, #86, #39, and #84. This was a random opportunity for discovery during the facility task medication storage and labeling. Facility census 97. Findings included: The Facility policy titled, Medication Storage Policy and Procedure dated 06/13/16, stated the following: -Labels for multi-use vials must include: ---The date the vial was initially opened or access (needle-punctured); During an observation on 04/03/19 at 8:02 AM, Licensed Practical Nurse (LPN) verified that one (1) of five (5) insulins. This was novo log, belonging to Resident #24. It did not have a date on the practically used multi-use vial of insulin. During an observation on 04/03/19 at 8:44 AM, LPN #6 verified the one (1) of four (4) multi-use vials of insulin did not have a date on the practically used multi-use vial of insulin. This was [MEDICATION NAME]belonging to Resident #86. During an observation on 04/03/19 at 8:48 AM, LPN #27 verified that two (2) of four (4) multi-use pens of insulin did not have a date on them to indicate the initial date that it was opened. The Basaglar Kwikpen belonged to Resident #39 and the [MEDICATION NAME] pen belonging to Resident #84. During an interview on 04/03/19 at 10:04 AM, Administrator was made aware of the insulins not having dates on them. She stated that she is disappointed because she has gone over that several times.",2020-09-01
227,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2019-04-03,770,D,0,1,P29Y11,"**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 laboratory test for Resident #80. Resident #80's physician ordered a [MEDICAL CONDITION] Stimulating Hormone (TSH) test to be performed on 12/08/18 and there was not evidence this test was performed. This was true or one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #80. Facility census: 97. Findings included: a) Resident #80 A review of Resident #80's medical record at 12:28 p.m. on 04/03/19 found a lab result for a TSH that was drawn on 11/27/19. The physician reviewed this lab report on 11/28/18 and wrote the following, This is improving. Next TSH should be drawn in 10 days and fax me the results. Ten (10) days from 11/28/18 would have been 12/08/18. The medical record contained no evidence that this TSH level was obtained on or around 12/08/18. An interview with the Nursing Home Administrator at 3:02 p.m. on 04/03/19 confirmed this TSH level was never obtained.",2020-09-01
228,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2019-04-03,773,D,0,1,P29Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that Laboratory testing was only performed when ordered by a physician and that when a Laboratory Testing was performed that the ordering physician was promptly notified of the results. Resident #80 had a [MEDICAL CONDITION] Stimulating Hormone (TSH) level obtained on 11/27/18 and there was no order in the medical record for this TSH. For Resident #38 the facility failed to notify the attending of a lab result. This was true for two (2) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifiers: #80 and #38. Facility census: 97. Findings included: a) Resident #80 A review of Resident #80's medical record at 12:28 p.m. on 04/03/19 found a lab result for a TSH that was drawn on 11/27/19. Further review of the medical record found no physician order for [REDACTED].>An interview with the Nursing Home Administrator at 1:38 p.m. on 04/03/19 confirmed there was no physician order for [REDACTED]. b) Resident #38 On 02/19/19, the facility collected a specimen for a Chem 7 and HGB A1C. (A Chem 7 test can be used to evaluate kidney function, blood acid/base balance, and your levels of blood sugar, and electrolytes. The hemoglobin A1C test tells you your average level of blood sugar over the past 2 to 3 months.) Review of the resident's electronic medical record at 1:00 PM on 04/03/19, found no evidence of the results of the Chem 7 and HgbA1c obtained on 02/19/19. At 1:29 PM on 04/03/19, the Director of Nursing was asked if she could find the results of the laboratory values for the Chem 7 and the HGB A1C 1C. At 3:03 PM on 04/03/19, the DON provided a copy of the laboratory report, obtained on 02/19/19. The report indicated the laboratory results were faxed to the facility at 2:07 PM on 04/03/19. The DON said the report had been in the physician's box awaiting his signature for the past 2 months. The DON provided a copy of a nursing note, dated 02/19/19 noting the lab results were received and faxed to the physician. The DON was unable to provide evidence the physician actually reviewed the faxed report.",2020-09-01
229,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2019-04-03,804,D,0,1,P29Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure Resident #36's food was at a safe and appetizing temperature during the noon meal on 04/01/19. This was a random opportunity for discovery. Resident identifier: #36. Facility census: 97. Findings included: a) Resident #36 Record review found Resident #36 was admitted to the facility on [DATE]. The resident was residing on the Reflections unit. The Reflections Unit required a code to be entered on a key pad to both enter and exit the unit. The unit houses 20 residents when full. The unit is not a certified Alzheimer's/Dementia unit. Residents on this unit have cognitive loss. Observation of the noon meal on 04/01/19 found the resident received his meal at approximately 12:30 PM. The Resident was seated alone at a table beside the back wall of the dining room. At 2:20 PM on 04/01/19, the Resident was still seated at the same table continuing to eat his noon meal. He had eaten his broccoli. A BBQ sandwich, tater tots, and milk remained. At 2:20 PM on 04/01/19, the resident's Licensed Practical Nurse (LPN) #15, said the Resident likes to eat, He will eat all day long, so we just let him. The resident's current care plan was reviewed with LPN #15. An intervention on the care plan noted the resident would receive food as an intervention to distract the resident from wandering. The care plan did not include providing continuous food. At 2:31 PM on 04/01/19, the dietary manager was asked to take the temperature of the resident's meal. The temperature of the BBQ was 64 degrees, tater tots were 66 degrees. The DM obtained the temperature of his milk and said, It's at 68 degrees and continuing to rise. The DM said the temperatures were not acceptable. We could do more meals a day, we have done that before. She said she did not realize the resident liked to have food all day long. The DM checked the pantry and said there is plenty of milk in the refrigerator and snacks are available. She said, At least the resident's tray needed to be heated in the microwave if he was going to take a long time to eat it. On 04/02/19 at 1:02 PM, the administrator said she was unaware of the above observation and interviews.",2020-09-01
230,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2019-04-03,842,D,0,1,P29Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #38's medical record was complete and legible. This was found for one (1) of twenty-one (21) records reviewed. Resident identifier: #38. Facility census: 97. Findings included: a) Resident #38 Review of the consultant pharmacist reports dated 04/16/18 and 11/15/18 found the pharmacist made medication recommendations after review of the Resident's current medications. The report required the physician to write a response, sign and date the recommendations. Review of a laboratory report of a [MEDICATION NAME] acid collected on 12/19/18 found the physician had made only a mark on the laboratory report. At 1:29 PM on 04/03/19, the Director of Nursing reviewed the consulting pharmacist reports. The DON confirmed she could not read the date the physician reviewed the 04/16/18 and 11/15/19 reports. The 04/16/18 reports had only a one single mark of a pen which was did not represent a month, day or year. She believed the report for 11/15/18 was signed in (MONTH) but she could not read the date or the year. The DON could not say the reports were reviewed timely when the physician's writing was illegible. In addition, the DON unable to read the date on [MEDICATION NAME] Acid lab from 12/19/18. She said the mark on the laboratory report was the physician's signature but she did not see a date.",2020-09-01
231,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2019-04-03,880,D,0,1,P29Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, medical record review, and staff interview the facility failed to the facility failed to ensure staff used appropriate infection control practices to prevent the development and transmission of infectious and communicable disease within the facility. Facility staff failed to use proper technique during perineal care to eliminate the spread of infectious diseases for Resident #16. Oxygen tubing was found to be maintained in an unsanitary manner for Resident #30. This was a random opportunity for discovery. This practice had the potential to affect more than an isolated number of Residents. Resident Identifiers: #16, #30. Facility Census: 97. Findings included: a) Resident #16 On 04/03/19 at 1:19 PM Nurse Aide (NA) #36 and NA #141 were observed as they provided perineal care (washing genitalia and surrounding area) for Resident #16. NA #36 presented to bedside with gloves donned (to put on gloves), with one wet soapy wash cloth, one wet wash cloth without soap, one dry wash cloth, and no wash basin. NA #36 draped all wash clothes across top of left upper bed rail and positioned Resident supine (on back), unfastened Resident's brief and folded the front of brief down and tucked it under the Residents buttock. Resident's brief was visibly soiled with a bowel movement and urine. NA #36 proceeded with perineal care by separating Resident's legs that were bent at the knees and very stiff (due to contractures) and made one wipe down the front of the perineum across the labia with the soapy wash cloth. NA #141 then assisted NA #36 to turn resident to her right side and NA #36 folded soiled soapy wash cloth over one time and wiped one pass up the Resident's buttocks. NA #36 then wiped the perineal area one time from front to back bewteen the buttocks with the wash cloth that was said to be a rinse wash cloth containing only water, then wiped one time between the buttocks with the dry wash cloth. NA #36 then pulled soiled brief out from under resident, rolled brief up and laid brief on top of trash bag on foot of bed with soiled washcloths on top. Without removing soiled gloves, NA #36 then walked over to resident's dresser, opened top drawer with soiled gloves on, shuffled through clothing and obtained heel protectors from drawer and placed them on resident. NA #36 then separated soiled brief from soiled washcloths, removed soiled glove from right hand only, and placed items in separate trash bags. While continuing to wear soiled glove on left hand, NA# 36 covered resident up with sheet with both hands, lowered bed with right ungloved hand, and placed call bell on resident's chest with left hand. NA#36 then removed soiled glove from her left hand and handed trash bags to NA# 141 for disposal, and went to bathroom and washed hands. Review of Perineal Care policy with revise date of 10/16/16 included the following instructions for perineal care for a female resident without an indwelling catheter: -Wet wash cloth and apply soap or skin cleansing agent. -Wash perineal area, wiping from to back. -Separate labia and wash area downward from front to back. -Continue to wash perineum moving from inside outward to and including thighs, alternating from side to side, and using downward [MEDICAL CONDITION]. Do not use same washcloth or water to clean the urethra or labia. -Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. -Gently dry perineum. - Instruct or assist the resident to turn on her side with her top leg slightly bent, if able. -Rinse wash cloth and apply skin cleansing agent. -Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Do not reuse the same wash cloth or water to clean the labia. -Rinse thoroughly. -Dry area thoroughly. -Discard disposable items into designated containers. -Remove gloves and discard into container. Wash and dry your hands thoroughly -Reposition the bed covers. Make resident comfortable. Review of employee record revealed NA #36 attended in-service training on 01/15/19 for education of perineal care and hand hygiene and successfully completed staff competencies for female incontinence care (perineal care) in bed and proper hand washing technique observed by Director of Staff Development Registered Nurse (RN) #20. During an Interview on 04/03/19 at 2:43 PM, Director of Staff Development Registered Nurse #20 verified NA# 36 was in attendance for in-service training on 01/15/19 for perineal care of residents, and NA #36 demonstrated competency in care area by successfully completing skills evaluation check off. b) Resident #30 During an observation on 04/01/19 at 11:06 AM, it was noticed the Nasal Cannula (NC) (oxygen tubing that goes in the residents nose) was on the floor. The oxygen machine running, Licensed Practical Nurse (LPN) #1 was asked to come to the room. She removed the tubing and said, that she was going to replace it with a new one. On 04/03/19 at 4:40 PM, Administrator was informed of findings.",2020-09-01
232,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2017-04-20,272,D,0,1,GGWL11,"Based on record review and staff interview, the facility failed to conduct an accurate comprehensive minimum data set (MDS) assessment for one (1) of nineteen (19) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). The comprehensive assessment for Resident #152 did not accurately reflect that the resident received an anticoagulant medication. Resident identifier: #152. Facility census: 104 Findings include: a) Resident #152 Medical record review, on 04/19/17 at 10:57 a.m., revealed an Medication Administration Record [REDACTED]. The comprehensive MDS assessment with the Assessment Reference Date (ARD) of 03/31/17 did not accurately indicate Resident #152 was receiving an anticoagulant. On 04/19/17 at 4:20 p.m., during an interview with the MDS Coordinator, she verified the MDS (Section N: Medications) with the ARD of 03/31/17 did not reflect Resident #152 as taking an anticoagulant.",2020-09-01
233,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2017-04-20,463,E,0,1,GGWL11,"Based on observation and staff interview, the facility failed to provide a means of communication allowing residents to call for staff assistance. Three (3) separate bathrooms were not equipped with a mechanism to allow residents to call for assistance. These bathrooms were located in the front lobby, on the rehabilitation hall and near the chapel. This practice had the potential to affect more than an isolated number of residents. Facility census: 104. Findings include: a) On 04/18/17 at 3:00 p.m., an observation was made of the bathrooms in the front lobby. These bathrooms were located near the sitting room, a gift shop, cafe and gathering room for residents. Observations revealed both male and female bathrooms were not equipped with a means of communication which would allow residents to call for staff assistance. There was no call system in the bathrooms. On 04/19/17 at 8:02 a.m., observations of the bathrooms near the chapel area also revealed these bathrooms did not have a call system for residents to use if they were in the bathroom and needed help. These bathrooms were labeled as Staff Only however, they were not locked and were located next to the facility's chapel which was for residents. A third observation, on 04/19/17 at 8:15 a.m., of a bathroom on the [NAME]lands[NAME]Rehabilitation side of the building also revealed a bathroom that did not have a call system for residents to use if they were in the bathroom and needed assistance. This bathroom was located in a hallway between the therapy gym and the hallway which housed resident rooms. On 04/19/17 at 11:30 a.m., during an interview with the administrator, she agreed the three (3) bathrooms mentioned above were not locked, and residents could have access to them. She also agreed the three (3) bathrooms did not have call systems that would allow residents to call for help if they were in the bathroom and needed assistance. The administrator said she would be able to equip these bathrooms with a call system but this would take some time. She said in order to ensure the resident's safety before the call systems were installed, she would lock the bathrooms, and a key would have to be requested in order to use the bathroom. She also mentioned putting a key pad locking system on the bathrooms near the chapel area.",2020-09-01
234,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2018-04-25,685,D,0,1,CEG811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician's orders to irrigate ears after the completion of treatment to loosen ear wax. This affected one resident of one reviewed for reviewed for hearing. Resident identifier: #90. Facility census: 94. Findings included: a) Resident #90 The medical record for Resident #90 was reviewed on 04/24/18 at 9:22 [NAME]M. Resident #90 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 30-day Minimum Data Set (MDS) assessment, dated 04/12/18, indicated the resident had adequate hearing. The physician's orders were reviewed and the Medication Administration Record [REDACTED]. The physician's orders directed staff to Instill application in both ears three times a day for ear wax for five days in ear canal with [MEDICATION NAME]. Irrigate with lukewarm tap water 20 minutes after last dose. A nurse's note dated 04/18/18 at 8:59 [NAME]M. stated the resident told the nurse she knew her ears were full of wax because the nurse yesterday told her so. The nurse called the physician and discontinued a 2nd round of the [MEDICATION NAME] Solution and ordered a consult with an ear specialist regarding possible ear wax impaction. On 04/23/18 at 10:32 [NAME]M. an initial interview was conducted with Resident #90. The resident stated she had been receiving drops in her ears for wax build up and the nurse was supposed to suction her ears out after the drops were completed and didn't. The resident stated she was going to go to an ear doctor because she could not hear well out of her right ear and the nurse said it was because it was full of wax. On 04/24/18 at 9:01 [NAME]M., Resident #90 was re-interviewed and was able to hear all questions asked during the interview. The resident was asked, Can you hear okay since you still have wax in your ears? The resident stated there were no problems with hearing. On 04/24/18 at 9:36 [NAME]M. Registered Nurse (RN) #138 was interviewed. RN #38 stated she tried to irrigate the resident's ears on 04/16/18 because the resident told her the nurse didn't do it when the last drops were given two days prior. RN #138 could not confirm if the nurse irrigated the resident's ears or not. RN #138 stated the resident was in the process of receiving an appointment with the ear doctor for an appointment for ear wax removal. On 04/24/18 at 2:24 P.M. the Interim Director of Nursing (DON) #45 was interviewed. Interim DON #45 stated the facility received physician orders on 04/8/18 for the [MEDICATION NAME] Solution for the resident's ears. The Interim DON #45 stated she called the nurse who was suppose to irrigate the ears on 04/14/18 on the last dose and the nurse stated she did not do it. The Interim DON #45 stated a second physician's order for another round of [MEDICATION NAME] Solution was ordered, but was discontinued and on 04/18/18 the physician ordered the resident to be seen by a ear doctor instead. The Interim DON #45 verified the nurse did not follow the physician's orders to irrigate the ears after the last dose of [MEDICATION NAME] Solution on 04/14/18.",2020-09-01
235,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2018-04-25,692,E,0,1,CEG811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure three of five residents reviewed for nutrition maintained acceptable body weight. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #84, #98 and #24. Facility census: 94. Findings included: a) Resident #84 The medical record for Resident #84 was reviewed on 4/24/18 at 4:45 PM. Resident #84 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 14 day assessment dated [DATE] revealed on Section K0300 the resident had a loss of 5% or more in the last month and received a mechanically altered diet. The plan of care dated 03/26/18 was reviewed on 4/24/18 at 4:51 PM. The plan of care revealed the following: Resident was at risk for weight loss due to poor oral intake. The Admission Weight was 114 pounds on 03/28/18 and Ideal Body Weight (IBW) was 100-120 pounds. The Resident will remain within IBW range. DIET: Pureed No Added Salt, ground meat with allowance for Mechanical Soft breads, snacks, & desserts and regular fluid consistency. Meals in Assisted Dining Room. [MEDICATION NAME] Acetate 40 milligram daily for appetite stimulant. Supplement: Ensure Plus three times a day. Weight as ordered. Potential for aspiration related to dysphagia. Will have no signs or symptoms of aspiration through next evaluation. Speech therapy five days per week for 4 weeks for cognitive skill training,speech/language and swallowing. Further review of the medical record on 4/24/18 at 5:10 PM revealed the following weights recorded for Resident #84: --4/24/18 - 107 pounds (lbs) --4/17/18 - 107 lbs --4/11/18 - 107 lbs --4/10/18 - 107 lbs --4/01/18 - 113 lbs --3/29/18 - 113 lbs --3/28/18 - 114 lbs A nutritional progress note dated 3/28/18 revealed the resident's weight upon admission was 114 pounds and the resident was 62 inches tall. The note further indicated the resident's current average oral intakes recorded were 40% breakfast, 30% lunch and 27% dinner since admission. The resident receives Ensure Plus three times a day and receives a Regular no added salt, Low Fat diet. No [MEDICAL CONDITION] or pressure ulcers noted upon admission. A nutritional progress note dated 3/28/18 revealed the resident received a no added salt, low fat diet. The note identified the recommendation to discontinue low fat part of diet order and also add [MEDICATION NAME] (supplement to promote weight gain) 4 ounces twice a day related to a low body mass index. A nutritional progress note dated 3/29/18 revealed a notice was received from nursing to take Low Fat off of diet. A nutritional progress note dated 4/11/18 revealed the diet order remained no added salt. Weight continues to be an issue. [MEDICATION NAME] started 3/29/18 will take at least 2 weeks to be effective. A nutritional progress note dated 4/13/18 revealed the resident's weight was 107 pounds on 4/11/18 and showed a significant weight loss of six pounds (5.3%) in one week from 4/01 - 4/10/18 and a significant weight loss of seven pounds (6.1%) since admission (3/28/18). The current average intake of meals were noted as 15% for breakfast and lunch and 5% for dinner. On 4/24/18 at 12:37 PM the resident was observed in the dining room eating lunch. Staff was observed sitting near resident and the resident was feeding self. On 4/25/18 at 10:40 AM, Registered Dietician (RD) #147 was interviewed. RD #147 stated he recommended [MEDICATION NAME] HN (supplement to promote weight gain) four ounces twice a day on 3/28/18. RD #147 stated he writes down his recommendations and takes them to Dietary Supervisor (DS) #95. DS #95 then gives them to the Interim Administrator #105 to get them implemented by the physician. RD #147 stated he did not know why the resident was not currently receiving the [MEDICATION NAME] HN supplement as recommended. RD #147 verified the resident had a seven pound weight loss since admission on 3/26/18 and the dietary note written on 4/13/18 revealed she had a decrease in meal intakes and no new interventions were recommended and no follow up had been done on why the supplement had not been implemented. On 4/25/18 at 10:45 AM Certified Dietary Manager (CDM) #148 was interviewed. CDM #148 stated on 4/13/18 she documented the resident's decrease in intakes for all three meals and identified the [MEDICATION NAME] HN supplement was not started as recommended on 3/28/18 by the RD. CDM #148 stated she did not follow up on the recommendation for the [MEDICATION NAME] HN supplement that had not been implemented and did not make any new recommendations to prevent further weight loss. On 4/25/18 at 10:47 AM DS #95 was interviewed. DS #95 stated she received the recommendation sheet from the RD and gave it to Interim Administrator #105 to get the recommendations to the physician. On 4/25/18 at 11:28 AM Interim Administrator #105 was interviewed. Interim Administrator #105 stated she received the recommendation from DS #95 on 3/28/18 for [MEDICATION NAME] HN supplement four ounces twice a day and to discontinue a low fat diet. Interim Administrator #105 stated the low fat diet was discontinued per the RD recommendations, but the [MEDICATION NAME] HN supplement four ounces twice a day was never acted upon per the recommendations of the RD. On 4/24/18 at 5:10 PM the weight assessment/intervention policy was reviewed. #5 of the weight policy indicated: If it is determined that there has been a significant weight loss, the following interventions will be started: Five interventions were listed and #3 indicated house or commercial supplements would be implemented. b) Resident #98 The medical record for Resident #98 was reviewed on 4/25/18 at 7:28 AM. Resident #98 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS quarterly assessment dated [DATE] and an annual MDS dated [DATE] were reviewed on 4/25/18 at 7:28 AM. The MDS's revealed on Section K0300 the resident had a loss of 5% or more in the last month or 10% in last six months and received a mechanically altered diet. The plan of care dated 4/4/18 was reviewed on 4/25/18 at 7:28 AM. The plan of care revealed the following: Resident had weight loss in past 180 days. The current weight was 116 pounds on 4/1/18 and IBW of 105-125 pounds. The Resident will remain within IBW range. Pureed Regular Diet. Fed by staff, people feeder cup, super cereal for breakfast, Glucerna Shake (Supplement) three times a day and weigh resident monthly. Further review of the medical record on 4/25/18 at 7:29 AM revealed the following weights recorded for Resident #98: --4/1/18 - 116 lbs --3/1/18 - 120 lbs --2/2/18 - 123 lbs --2/1/18 - 120 lbs --1/2/18 - 126 lbs --1/1/18 - 125 lbs --12/1/17 - 132 lbs --11/22/17 - 130 lbs --11/1/17 - 138 lbs --10/1/17 - 138 lbs On 4/25/18 at 12:13 PM the nutritional progress notes were reviewed. A nutritional note documented by CDM #147 dated 10/10/17 revealed the resident's current weight on 10/1/17 was 138 pounds. This showed a weight loss of 4 pounds (2.8%) in 30 days, a weight loss of 8 pounds (5.4%) in 90 days, and a significant weight loss of 22 pounds (13.7%) in 180 days. The current average meal intakes recorded were 51% at breakfast, 94% at lunch and 49% dinner. The resident received a pureed regular diet and received Glucerna Shake (nutritional supplement) 8 ounces (oz) three times a day. A nutritional note documented by CDM #147 dated 3/1/18 revealed the resident's current weight on 2/2/18 was 123 pounds. This showed a weight loss of 3 pounds (2.3%) in 30 days, a significant weight loss of 15 pounds (10.8%) in 90 days, and a significant weight loss of 18 pounds (12.7%) in 180 days. The current average meal intakes recorded were 69% at breakfast, 63% at lunch, and 43% at dinner. The note identified the resident received Glucerna Shake three times a day with fair intake recorded for 7 days, a pureed regular diet and super cereal for breakfast. Will recommend to discontinue Glucerna Shake and start 2 Cal HN 2 oz three times a day with medication pass due to weight loss. A nutritional note documented by RD #148 dated 3/7/18 revealed the diet order remains appropriate. History of weight loss over last few months. Agree with recommendations from (CDM #147) on 3/1/18 for supplements. A nutritional note documented by CDM #147 on 4/4/18 revealed the resident's current weight on 4/1/18 was 116 pounds. This showed a weight loss of 4 pounds (3.3%) in 30 days, a weight loss of 9 pounds (7.2%) in 90 days, and a significant weight loss of 22 pounds (15.9) in 180 days. The current average meal intakes recorded were 68% at breakfast, 96% at lunch, and 61% at dinner. The note indicated the resident receives an at bedtime snack with 0% intake recorded in 7 days. Receives super cereal for breakfast. Received Glucerna Shake 8 oz three times a day. Received a Pureed Regular diet. A nutritional progress note documented by the RD #148 on 4/4/18 revealed: Reviewed and agree with CDM note on 4/4/18. Diet order and interventions remains appropriate. Observation was made on 4/23/18 on 12:33 PM of the resident being fed lunch by a family member. There was no supplement on the tray. The nurse was notified and the resident was provided the supplement. On 4/24/18 at 8:34 AM the resident was observed in the dining room being fed by staff. The diet card was followed and included the supplement and super cereal. On 4/25/18 at 10:56 AM the RD #148 was interviewed. Resident #98's weights, nutritional notes, supplements and weight loss was reviewed. The RD verified the resident had weight loss and in (MONTH) (YEAR) weighed 138 pounds and weight on 4/1/18 was 116 pounds. The RD stated the resident has received Glucerna 8 ounces three times a day for quite sometime. The RD stated the resident received super cereal (enhanced cereal with additional calories) at breakfast, but was not sure for how long and was not certain how many calories were in the enhanced super cereal. The RD stated that nursing does not document the consumption of the super cereal separate from other foods and all foods is calculated together on the meal intake records. The RD verified he did not know if the resident consumed the super cereal or not. The RD stated he used the CDM's documentation to do his assessment. The RD verified that on 4/4/18 in his documentation he agreed with the CDM's note to continue with interventions and did not make any recommendations for any new interventions related to resident's continued weight loss. On 4/25/18 at 11:18 AM CDM #147 was interviewed. The CDM stated no additional recommendations were made based on the 4/4/18 evaluation, despite the resident's continued weight loss. The CDM verified the resident received super cereal, but did not know how long the resident had received it. The CDM stated the consumption of the super cereal was not tracked separately by staff on meal intake records, so she didn't know if the resident ate it or not. The CDM verified she had not made any additional recommendations for interventions despite the resident's continued weight loss when she reviewed the resident on 4/4/18. On 4/25/18 at 11:23 AM, Licensed Practical Nurse (LPN) #8 was interviewed and stated she did not know what super cereal was, but she had never documented the consumption of it in her documentation. On 4/25/18 at 11:24 AM, Certified Nurse Aide (CNA) #86 was interviewed. CNA #86 stated the super cereal is calculated together with all the other foods the resident eats and is not calculated separately on the meal intake records. On 4/25/18 at 11:26 AM, Dietary Supervisor (DS) #95 was interviewed. The DS #95 stated a physician's orders [REDACTED]. c) Resident #24 Resident #24 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/24/18 at 2:18 PM. Resident #24's most recent MDS, dated [DATE], was reviewed. It revealed the resident was independent for eating and required staff set up her meals, after which she could feed herself. She was noted to be cognitively impaired with no swallowing problems and her weight was documented to be 117 pounds. She was noted to have had a weight loss of 5% or more and was not on prescribed weight loss program. Review of Resident #24's nutrition care plan dated 2/26/18 on 4/24/18 at 2:30 PM. documented she left 25% or more of her food uneaten at most meals. Her current weight was documented to be 120 pounds with a usual body weight of 116-133 pounds. Care plan interventions included for staff to assist her with meals as needed, provide a regular diet and give supplements as ordered. Review of Resident #24's current physician orders [REDACTED]. revealed she received a regular diet with regular texture. Review of her nutrition assessment dated [DATE] revealed she received a regular diet and a nutritional supplement of 2 Cal HN (high calorie nutritional supplement). The assessment documented Resident #24 eats about 50% of meals and her Ideal body weight is 120 pounds. Continued review of the clinical record revealed Resident #24's recent weights were documented as follows: --4/17/18 - 110 lbs --4/10/18 - 116 lbs --4/3/18 - 113 lbs --3/27/18 - 116 lbs --3/21/18 - 119 lbs --3/14/18 - 119 lbs --3/7/18 - 117 lbs --3/6/18 - 118 lbs --2/28/18 - 118 lbs --2/21/18 - 119 lbs Review of CDM #147's nutrition progress note on 4/24/18 at 3:15 PM. dated 3/20/18, revealed a note indicating Resident #24 had triggered for weight loss. Her height was documented to be 64 inches, Body Mass Index (BMI) of 20.4 and a current weight of 119 pounds. This progress note documented a significant weight loss of 14 pounds (10.6%) x 180 days. The note revealed the resident prefers her meals in the Reflections Unit and can feed herself after the staff set her up with her meal. The resident's average meal intakes were recorded as being 69% breakfast, 25% lunch, 30% dinner. Documentation also revealed the resident received 2 Cal HN 240cc three times a day when she receives her medication. She was noted to have no [MEDICAL CONDITION] or pressure ulcers and the staff were doing weekly weights. The documentation revealed the staff will continue to monitor the resident's weights and intake. Review of RD #148's progress note dated 3/28/18 revealed he agreed with CDM Staff #147's 3/20/18 note and that the residents diet order and supplements remained appropriate. Review of CDM #147's nutrition progress note dated 3/28/18 revealed Resident #24's BMI was now down to 19.9 with a current weight of 116 pounds. This progress noted documented a significant weight loss of 15 pounds (11.4%) in the past 180 days. The current average meal intakes were recorded indicating the resident consumed 35% of her breakfast, 14% lunch and 30% at her dinner meals. The documentation also revealed she received 2 Cal HN 240cc three times a day when she receives her medications. The documentation revealed she consumed an average of 50% of the 2 Cal HN when it was offered to her. Staff were to continue to monitor weights and no new interventions were implemented despite the noted significant weight loss in the past 180 days. Review of a nutritional progress note dated 4/12/18 revealed Resident #24 triggered for a weight review and her current weight was noted to 109 pounds. This weight indicated a significant weight loss 8 pounds (6.8%) x 30 days, a significant weight loss of 13 pounds (10.6%) x 90 days and a significant weight loss of 21 pounds (16.1%) x 180 days. The resident's average meal intakes were recorded as an average of 12% at breakfast, 7% at lunch and 19% at supper. The documentation revealed she received 2 Cal HN 240cc three times a day with an average consumption of 115cc of the 240cc ordered over the past 7 days. She was noted to refuse the 2 Cal HN at times. CDM #147 made no new recommendations to address Resident #24's decreased meal intake and continued weight loss. Review of a nutritional progress note dated 4/18/18 from RD #148 revealed he agreed with CDM #147's 4/12/18 note, indicating Resident #24's diet order remained appropriate and no new interventions were recommended to address the decreased meal intake and continued weight loss. Review of the current facility weight policy, dated 8//30/16, on 4/24/18 at 11:00 AM. revealed the dietary director or designee will assess residents to determine if there has been a significant loss of more than 5% within 30 days or 10% within 180 days. The Dietary director will discuss at the weekly clinical meetings any significant weight change. If it is determined that there has been a significant weight loss the following interventions will be started: Placed on weekly weights; Alter the residents portion sized if the resident can consume; House or commercial supplements. Other interventions such as extra milk, pudding, special requests from resident or family and to include them in the assisted dining or restorative dining program. Any significant weight loss with no explanation for the loss will be placed on a 3-day calorie count. Nursing will notify the responsible party of the significant weight change. Observation of Resident #24 on 4/24/18 at 12:12 PM. revealed she was seated in the dining room feeding herself lunch. She consumed about 30 % of her meal. She was noted to drink her hot chocolate and eat her dessert and ate minimal other food on her tray. Observation again on 4/25/18 at 12:05 PM revealed Resident #24 seated in the dining room feeding herself. She ate 30 % of her meal and was again noted to drink her hot chocolate and eat her dessert and ate minimal other food on her tray. Interview on 4/25/18 at 11:22 AM. with Certified Nurse Aide (CNA) #90 and #121 revealed Resident #24 had not been eating very well over the past few months. They stated she loves dessert and hot chocolate and that is about all she will eat. They both stated she does not get any scheduled snacks, but they believe the nurse gives her a supplement with her medication. Interview with Licensed Practical Nurse (LPN) #27 on 4/25/18 at 11:30 AM revealed she does offer the resident a supplement with her medications but she does not always take it and if she does she will only consume part of it. An interview was conducted with RD #148 on 4/25/18 at 8:40 AM. He verified Resident #24 had experienced a significant weight loss and had lost 9 pounds in the past month. He stated there should have been an intervention to address the weight loss when the resident was noted to have lost 10 pounds and was not consuming the ordered supplement consistently and had poor meal intake. Interview with CDM #147 on 4/25/18 at 9:12 AM revealed she conducts all the nutritional assessments and the RD #148 reviews them when he is in the building once a week. She verified Resident #24 had experienced a significant weight loss over the past 180 days and there had been no new dietary interventions to address the weight loss. In an interview on 4/25/18 at 11:51 AM with Dietary Staff #46 and CDM #147 they both indicated the resident did not have any dislikes on her diet card, but she did receive hot chocolate for every meal. They verified they had never spoke with staff about what Resident #24 might like to have based on what she consumed the most of on her meal tray in increase her food consumption. They were not aware that the resident likes sweets and desserts. When this was shared they stated the resident may benefit from high calorie milk shakes or pudding between meals to assist with her weight loss. They verified she does not receive any snacks in between meals but stated they should consider adding them. CDM #147 verified she was not aware of the protocol noted on the facility weight policy regarding the required interventions to be implemented if a resident was noted to have a significant weight loss. She verified she had not attempted interventions such as extra milk, pudding or special requests from resident or family, nor had the resident been included in the assisted dining or restorative dining program. She also verified that although the resident had experienced and significant weight loss with no explanation, she had not ben placed on a 3-day calorie count. During this interview, Dietary Staff #46 verified Resident #24 had a significant weight loss over the past 2 months. She also verified Resident #24 should have had interventions to address the weight loss to maintain her desired nutritional parameters. This information was shared with the Administrator on 4/25/18 at 1:05 PM.",2020-09-01
236,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2018-04-25,758,D,0,1,CEG811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to conduct gradual dose reductions for [MEDICAL CONDITION] drugs in an effort to discontinue those drugs for one of six residents reviewed for Unnecessary Medications. Specifically, the facility failed to attempt a gradual dose reduction for Resident #100's anti-psychotic medication. [MEDICATION NAME], with no evidence of justification for the medication. Resident identifier: #100. Facility census: 94. Findings included: a) Resident #100 The behavior management policy, last revised on 05/30/17, was provided by the interim director of nursing (DON) on 04/25/18 at 9:48 AM. The policy read in pertinent part: --It is the policy of this facility to enhance the quality of life for each resident by assuring the optimal level of functioning with the least restrictive yet safe environment. A [MEDICAL CONDITION] drug is any drug that affects brain activities . These drugs include drugs in the following categories: anti-psychotic . Initiate and maintain a behavior monitoring record . Attempt to manage the behavior through non-pharmacological interventions . Notify the legally responsible party if medical intervention is needed and complete informed consent for psycho-active medication consent and have signed . Maintain clinical documentation to record behavior exhibited and response to interventions and observation of continued behaviors . If medication is necessary, monitor for side effects and the resident's response to the medication and any unusual drowsiness . New physician orders [REDACTED]. Medications will be monitored by the consultant pharmacist, DON or his/her designee and dose reduction attempted at least every three to six months as ordered by physician. Resident #100 admitted to the facility on [DATE], with a current [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessments and care plans were reviewed on 04/24/18 at 9:26 AM. According to the 04/3/18 MDS assessment, the resident was rarely or never understood. He had short term and long term memory problems. He exhibited no behaviors. The resident was totally dependent on staff for all activities of daily living (ADL). The care plan, initiated 03/18/18 and revised 04/18/18, identified the resident received a daily anti-psychotic medication and was at risk for adverse side effects. Interventions included collaborating with the provider to identify opportunities to decrease medication dosage and then evaluate for new or recurring behavioral symptoms. The care plan, initiated 01/25/17 and revised 04/15/18, identified the resident had impaired cognitive function related to [MEDICAL CONDITION] as evidenced by hitting, pinching and grabbing during care. Interventions included offering non-pharmacological interventions to resident such as a back rub, offering snacks, repositioning as well as if the resident becomes combative or agitated with care then staff were to return later to provide care if possible when the resident had calmed down. On 04/23/18 at 3:37 PM, the resident was lying in bed with his eyes closed. He was unable to be aroused when spoken to. The resident's roommate indicated the resident slept all day. Earlier in the day, the resident was sitting up in his wheelchair with his eyes closed. He was unable to be aroused when spoken to. On 04/24/18 at 8:57 AM, 2:35 PM, and 3:36 PM, the resident was observed to be lying in bed with his eyes closed. The resident's representative was interviewed on 04/24/18 at 9:03 AM. She explained the resident was at another nursing facility for a few months prior to his admission at this facility. She indicated she was not aware the resident received the anti-psychotic medication [MEDICATION NAME]. She said that the resident had never had any behaviors or been aggressive with staff that she was aware of. She said the staff had always told her that he was a great patient. She did not feel that the medication was necessary. She wondered if the medication contributed to the resident's drowsiness. She indicated the resident had stopped speaking over the past several months. The resident's representative was interviewed again on 04/25/18 at 9:43 AM. She said the facility had called her the previous night and informed her that she had signed the consent for [MEDICATION NAME] back in (MONTH) (YEAR). They provided her with the consent, but she still could not remember signing the paperwork. She could not believe that she would sign it. She again stated that the resident had never had any behaviors. She said the resident did not have any behaviors at the previous facility either, except he would call out sometimes. She said when the facility called her last night, they told her they were going to get him off of the [MEDICATION NAME]. She hoped the resident had not become addicted to the medication resulting in side effects or withdrawal after getting him off of the medication. She did not believe the medication was necessary. The 4/18 physician orders [REDACTED]. The resident had the following orders: 11/27/17 - Quetiapine [MEDICATION NAME] ([MEDICATION NAME]) 25 milligram one tablet by mouth at bedtime related to dementia with behavioral disturbance. 11/27/17 - Resident receives [MEDICATION NAME] for dementia with behavior disorder AEB (as evidenced by) verbal aggressive behaviors. On 04/15/18, the order was revised to include the behaviors of grabbing and hitting. Staff were to observe for these behaviors during each shift and document whether the behavior was present or not. The resident had zero behaviors documented for the month of (MONTH) (YEAR). 12/27/17 - Resident receives [MEDICATION NAME] for dementia with behaviors. Observe for side effects or medication such as changes in appetite, dry mouth or drowsiness. The staff were to document if the side effects were present or not. There were no documented side effects for the month of (MONTH) (YEAR). Further review of the resident's medical record was completed on 04/24/18 at 10:00 AM. Review of the psychoactive medication informed consent revealed the resident's representative had signed the form on 01/23/17, the day of admission. The consent was for 25 mg of [MEDICATION NAME] every night. The form did not document that any non-drug approaches had been ineffective. The medical [DIAGNOSES REDACTED]. The target symptoms were restlessness and agitation. The beneficial effects were no more restlessness or agitation. The proposed course of the medication was indefinite. Review of the pharmacy recommendations revealed the pharmacist had recommended a gradual dose reduction (GDR) five times since admission. On 02/3/17, the recommendation documented in pertinent part, (Resident #100) has dementia and receives an antipsychotic, Quetiapine 25 mg hs (at night). Recommendation: Please consider reducing the dose of Quetiapine [MEDICATION NAME] to 12.5 mg hs with the eventual goal of discontinuation, while concurrently monitoring for re-emergence of target and/or withdrawal symptoms. This recommendation was declined by the physician documenting that the resident was stable. On 04/14/17, the recommendation documented in pertinent part, (Resident #100) has received Quetiapine [MEDICATION NAME] 25 mg daily for behavioral or psychological symptoms of dementia since 01/23/17. Recommendation: Please consider a gradual dosage reduction to 12.5 mg daily, with the end goal of discontinuation of therapy. The Director of Nursing (DON) at the time wrote on the form, Resident does well on this dose. Therefore the physician declined the recommendation. On 10/20/17, the recommendation documented in pertinent part, (Resident #100) receives [MEDICATION NAME] 25 mg hs for behavioral or psychological symptoms of dementia since 01/23/17. Regulations require at least a quarterly review to determine the effectiveness of the antipsychotic and the potential for reducing or discontinuing the dose. No reduction has been attempted. Recommendation: For the initial attempt at gradual dose reduction (GDR) in the facility, please consider decreasing to 25 mg every other day at bedtime while concurrently monitoring for re-emergence of target and/or withdrawal symptoms. Please note: Per federal nursing facility regulations, this individual does not meet criteria for GDR to be deemed clinically contraindicated because a GDR has not yet been attempted in the facility following the most recent admission. This recommendation was declined by the physician documenting that the resident was stable. On 01/12/18, the recommendation documented in pertinent part, (Resident #100) receives [MEDICATION NAME] 25 mg hs for behavioral or psychological symptoms of dementia since 01/23/17. Regulations require at least a quarterly review to determine the effectiveness of the antipsychotic and the potential for reducing or discontinuing the dose. No reduction has been attempted. Recommendation: For the initial attempt at gradual dose reduction (GDR) in the facility, please consider decreasing to 25 mg every other day at bedtime while concurrently monitoring for re-emergence of target and/or withdrawal symptoms. Please note: Per federal nursing facility regulations, this individual does not meet criteria for GDR to be deemed clinically contraindicated because a GDR has not yet been attempted in the facility following the most recent admission. This recommendation was declined by the physician documenting that the resident was stable. On 04/16/18, the recommendation documented in pertinent part, (Resident #100) receives [MEDICATION NAME] 25 mg hs for behavioral or psychological symptoms of dementia since 01/23/17. Regulations require at least a quarterly review to determine the effectiveness of the antipsychotic and the potential for reducing or discontinuing the dose. Recent eMAR (electronic medication administration record) indicates no aggressive behaviors. Recommendation: Please consider decreasing to 25 mg every other day at bedtime for 14 days then discontinue while concurrently monitoring for re-emergence of target and/or withdrawal symptoms. Please note: Per federal nursing facility regulations, this individual does not meet criteria for GDR to be deemed clinically contraindicated because a GDR has not yet been attempted in the facility following the most recent admission. This recommendation had the following comment from the interim DON, Reviewed with doctor by phone and received order to DC (discharge) [MEDICATION NAME]. Order written 04/24/18. Review of the physician progress notes [REDACTED]. There was no rationale for the continued use of [MEDICATION NAME]. Review of the MAR from 01/17 to 04/18 revealed that the resident was observed to have restlessness or agitation on three dates, 05/12/17, 06/26/17, and 06/27/17. The resident was not observed to have any side effects from the [MEDICATION NAME] from 01/17 to 04/18. Review of all progress notes from 01/17 to 04/18 revealed the resident was mostly pleasant and cooperative with staff. There was a behavior note from 06/26/17 that the resident became combative and was hitting staff while applying a cream to the resident's face. No other behavior concerns noted. On 4/24/18 at 7:26 PM, the interim DON documented in the progress notes her conversation with the doctor and resident's representative. She called the doctor and requested a dose reduction trial for [MEDICATION NAME] and the doctor told her to discontinue the medication. Certified nurse aide (CNA) #120 was interviewed on 04/24/18 at 3:50 PM. She had worked at the facility for two years, so she was very familiar with the resident. She said he had never had behaviors since being at the facility. The resident had never verbalized anything to her. He was only able to grunt. The resident always had his eyes closed. He was not always asleep, he just had his eyes closed. She said the resident was never combative. He was physically incapable of being combative because he was too contracted. She never had any issues with the resident. The Director of Social Services (DSS) and Social Worker (SW) #88 was interviewed on 04/24/18 at 4:01 PM. The DSS indicated they had a meeting every week to report on [MEDICAL CONDITION]. They talked about who had came on and off [MEDICAL CONDITION]. The SW said the resident was nonverbal. He used to be able to say a couple words, but now he was unable to talk. The resident did not move very much and he did not have any behaviors. He was not combative. She said the resident was admitted on [MEDICATION NAME]. He was on it at his previous facility. She thought he may have had more behaviors when he was there. Both the DSS and SW said that nursing was the one that kept track of GDRs (gradual dose reductions) and discussed changes to medications. They both indicated that the physician did not like to do dose reductions. The interim DON was interviewed on 04/24/18 at 4:17 PM. She started at the facility towards the end of (MONTH) (YEAR). She believed the resident was taking [MEDICATION NAME] due to a history of behaviors. She said the resident did not currently have behaviors. She could not speak to when he was first admitted . She confirmed the resident was admitted on the [MEDICATION NAME] and there had been no changes to the medication since admission. She said that a dose reduction should have been attempted sometime over the last year. She confirmed that the pharmacy had made several recommendations for a dose reduction, but the doctor had always declined the recommendation due to the resident being stable. She said there was not much she could do if the doctor did not agree with the pharmacist for a dose reduction. She said she would try to speak with his doctor to get a dose reduction. The interim DON was again interviewed on 04/25/18 at 9:48 AM. She said she had spoken with the doctor and received an order to discontinue the [MEDICATION NAME].",2020-09-01
241,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2020-02-13,558,D,0,1,G76I11,"Based on observation and interview, the facility failed to ensure a call light and bed controller was accessible and within reach for two (2) residents. This was a random opportunity for discovery. Resident identifiers: #26 and #313. Facility census: 62. Findings included: a) Resident #26 On 02/10/20 at 3:02 PM, Resident #26's call light and bed controller were not in reach. The call light and bed controller were located at the head of the bed, behind the headboard on the left side of the headboard. Resident #26 was lying across the middle of the bed. Resident #26's feet were on the floor, body angled across the bed, and her head lying near the wall. Resident #26 had a nutritional shake in her hand and was yelling, I can't get up, I can't drink my milk. On 02/10/20 at 3:04 PM, Employee #[AGE], Nursing Assistant (NA), entered the room when asked by the surveyor. On 02/10/20 at 3:06 PM, Employee #6, NA, entered Resident #26's room to assist NA #[AGE]. On 02/10/20 at 3:09 PM, Employee #6, Nursing Assistant, placed the call light and bed controller after the surveyor asked where the call light and bed controller were located. On 02/12/20 at 3:13 PM, 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 0[DATE]20. b) Resident #313 On 02/11/20 at 8:53 AM, Resident #313's bed controller was observed to be located behind the headboard, on the right side of the bed. Resident #313, who has capacity to make medical decisions, was asked if he could adjust his bed. Resident #313 stated that the did not know where the controller was located. On 02/11/20 at 9:01 AM, Employee #96, Clinical Quality Consultant, placed the bed controller in reach of Resident #313. On 02/12/20 at 3:13 PM, 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 0[DATE]20.",2020-09-01
242,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2020-02-13,583,D,0,1,G76I11,"Based on observation and staff interview, the facility failed to ensure resident privacy. This was a random opportunity for discovery. This failed practice had the potential to affect a limited number of residents. Resident identifier: #26. Facility census: 62. Findings included: a) Resident #26 During the initial tour of the facility on 02/10/20 at 11:18 AM, Resident #26's window blinds handle, used to opening and closing the blinds, was observed to be off of the blinds and lying in the windowsill. On 02/10/20 at 11:22 AM, Employee #51, Maintenance Assistant, entered the room. Employee #51 examined the window blinds and attempted to place the handle back on the window blinds. Employee #51 stated that the window blinds were broken. Employee #51 stated that she would have someone repair the window blinds that day. Employee #51 was asked if the blinds could be pulled to allow the resident privacy since Resident #26's bed was against the wall as well as located on the side of the room with the window. Employee #51 stated that the blinds could not be closed. On 02/10/20 at 3:02 PM, the window blind was still broken and the handle to the window blind was still lying in the windowsill. Employee #[AGE], Nursing Assistant (NA), was asked to enter the room since Resident #26 was calling for help. On 02/10/20 at 3:06 PM, Employee #6, NA, entered the room to assist NA #[AGE] with providing care for Resident #26. On 02/10/20 at 3:09 PM, after Resident #26 was transferred to her wheelchair, the surveyor asked NA #6 and NA#[AGE] what do they do when providing personal care to Resident #26 since the window blinds do not close. NA #6 and NA #[AGE] stated that Resident #26 takes herself to the bathroom. When NA #6 and #[AGE] were asked how do staff members ensure privacy when assisting Resident #26 with changing clothes, assisting with bathing, or any other aspect of care, NA #6 and NA #[AGE] did not provide an answer. On 02/11/20 at 9:04 AM, the window blinds for Resident #26 were still broken, with the handle lying in the windowsill. On 02/11/20 at 9:06 AM, the Director of Nursing (DON), was asked to enter Resident #26's room. The DON examined the window and window blinds, stating that the blinds could not be adjusted, nor opened and / or closed, and she would have someone fix the blinds. On 02/12/2020 at 3:13 PM, the findings were discussed with the Administrator and the DON. No further information was provided prior to the end of the survey on 0[DATE]20.",2020-09-01
243,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2020-02-13,684,D,0,1,G76I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice. This was a random opportunity for discovery. Resident identifier: #26. Facility census: 62. Findings included: a) Resident #26 During the initial tour of the facility on 02/10/20 at 11:18 AM, a fall mat was observed to be propped up against the exterior wall of Resident #26's room. The fall mat was located between the exterior wall and the tv cabinet. On 02/10/20 at 11:22 AM, Employee #52, Maintenance Assistant, observed the fall mat leaning against wall. On 02/10/20 at 3:02 PM, Resident #26 was lying across the middle of the bed. Resident #26's feet were on the floor, body angled across the bed, and her head lying near the wall. The fall mat was laying on the floor beside of Resident #26's bed. Employee #[AGE], Nursing Assistant (NA) entered Resident #26's room on 02/10/20 at 3:04 PM and NA #6 entered Resident #26's room at 3:06 PM. Both NA #6 and NA #[AGE] noted that the fall mat was located beside Resident #26's bed. A review of Resident #26's physician orders [REDACTED].#26 did not have an order for [REDACTED]. On 02/11/20 at 9:06 AM, the Director of Nursing (DON) entered Resident #26's room with the surveyor. The DON noted that the fall mat was against the exterior wall, between the wall and the tv cabinet. In an interview with the DON on 02/11/20 at 2:10 PM, the DON stated Resident #26 did not have an order for [REDACTED]. The findings were discussed with the Administrator and the DON on 02/12/2020 at 3:13 PM. No further information was provided prior to the end of the survey on 0[DATE]20.",2020-09-01
244,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2020-02-13,812,E,0,1,G76I11,"Based on observations and interviews with facility staff, the facility failed to maintain kitchen appliances in a sanitary manner. Equipment was found to be in need of cleaning. This practice has the potential to affect more than a limited number of residents who receive food served from this central location. Facility census: 62. Findings included: a) During the initial tour of the dietary department on 02/10/20 prior to lunch revealed the dietary staff had not followed proper sanitary techniques. The tour was performed with the Assistant Food Service Director, Employee #26, The following issues were noted at the time: 1. A reach-in freezer did not contain an internal thermometer which would allow the staff to determine if the unit was keeping the correct temperature. This is to ensure the food items are maintained in safe temperatures levels for consumption. 2 The milk cooler located near the serving line was found to have many spills in the bottom of the unit and to be in need of cleaning. 3. Drip pans under the range top had a large accumulation of food debris and in need of cleaning. 4. Oven doors had a greasy buildup both on the inside and outside the unit that needed cleaned. The handles of the doors were found to need cleaning as they were greasy and sticky to the touch. 5. The toaster was noted to have a large accumulation of crumbs and debris This was after the unit had been used for breakfast and had not been cleaned as yet.",2020-09-01
245,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2020-02-13,867,D,0,1,G76I11,"Based on record review and staff interview, the facility failed to ensure the Quality Assessment and Assurance (QA&A) committee corrected quality deficiencies it had or should have had knowledge of. This practice has the potential to effect all residents currently residing in the facility. Facility census: 62. Findings included: a) Cross reference deficiency cited at F 8[AGE] During an interview on 0[DATE] at 8:44 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 deficient practice. The Administrator discussed future ways that they would track and trend with regard to the pneumococcal vaccinations. No further information was provided prior to the end of the survey on 0[DATE]20.",2020-09-01
246,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2020-02-13,880,E,0,1,G76I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, 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 a random opportunity for discovery. Resident identifiers: #62 and #25. Facility census: 62. Findings included: a) Resident #62 On 02/11/20 at 11:34 AM, surveyor entered Resident's room with Registered Nurse (RN) #32 to observe wound care. Upon entering the room, observation was made of contracted hospice nurse assistant (HNA) providing incontinence care to the Resident #62. The HNA tossed the soiled wash clothes and towels smeared with dark brown substance that appeared to be stool over her shoulder onto the floor on top of a pile of existing dirty linens. The soiled linens were noted not to be in a bag or have any barrier between them and the floor. The dirty pile of linens created by the HNA was approximate two (2) feet into the doorway of the resident's room, and surveyor had to step over the dirty linens in order to enter room. RN# 32 was asked if she agreed with the procedure the HNA used for handling and disposing of the soiled linens, and RN#32 stated, No way, I saw that, they should have been placed in bag and not just tossed in the floor. At 11:49 AM on 02/11/20, surveyor informed Infection Control Nurse RN# 66 of surveyor's observation that occurred for Resident #62. RN #66 stated, Oh no, that's not our staff but they still should know better. During an interview at 12:35 PM on 2/11/20, the Director of Nursing (DON) stated, I have a call out the hospice agency the nursing assistant works for and will address her performance issues with the way she handled the soiled linens, and will be providing education all staff. b) Resident #25 During the initial tour of the facility on 02/10/20 at 11:19 AM, Resident #25's oxygen tubing was observed to be lying on the floor. Resident #25's nebulizer was observed sitting on the nebulizer machine. On 02/10/20 at 11:20 AM, Employee #47, Nursing Assistant (NA), was asked if the oxygen tubing was supposed to be on the floor. NA #47 stated the tubing was supposed to be in a bag. NA #47 stated that she would go get a nurse. On 02/10/20 at 11:24 AM, Employee #9, Licensed Practical Nurse (LPN), entered Resident #25's room. LPN #9 stated the oxygen tubing was supposed to be placed in a bag. LPN #9 further stated the nebulizer was supposed to be stored in a bag. A review of Resident #25's medical record noted a physician order [REDACTED]. On 02/12/ at 3:13 PM, 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 0[DATE]20. c) room [ROOM NUMBER] During the initial tour of the facility on 02/10/20 at 11:36 AM, soiled towels were observed in the floor of room [ROOM NUMBER]. These linens appeared to be wet, discolored, and gray smudges, roughly a quarter size in diameter, on them. The towels were found outside of the bathroom in room [ROOM NUMBER], near the closet area of room [ROOM NUMBER]. Employee #14, Housekeeping, stated she would remove the towels and place them in the soiled linen. A review of the facility's policy entitled, Infection Prevention and Control Program revealed the following: 10. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens so as to prevent spread of infection. d. Soiled linen shall be collected at the beside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom. e. Environmental services staff shall not handle soiled linen unless it is properly bagged. Unless resident and / or family representative prefers; soiled linen may be kept in resident room and / or bathroom if kept in an enclosed container. A review of the facility's policy entitled, Handling Soiled Linen, noted the following: 3. Guidelines for handling, storage, processing, and transporting linens include, but are not limited to, the following: a. Linen should not be allowed to touch the uniform or floor. 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. Soiled linen should not be kept in the resident's room or bathroom unless resident and / or family representative prefers otherwise, in which case soiled linen may be kept in resident's room and / or bathroom in an enclosed container. On 02/12/2020 at 3:13 PM, 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 0[DATE]20.",2020-09-01
247,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2020-02-13,883,D,0,1,G76I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop, maintain and follow policies and procedures for immunization of residents against pneumococcal disease in accordance with national standards of practice for two (2) of five (5) residents reviewed for the provision of immunizations. Resident identifiers: #62, #20. Facility census: 62. Findings included: a) Resident #62 Record review indicated Resident #62, [AGE] years of age, was administered 13-valent pneumococcal conjugate vaccine (PCV13) vaccine on 08/17/16. No documentation was found to indicate the resident either received the 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23) or did not receive the vaccine due to medical contraindications, previous vaccination, or refusal. During an interview on 02/12/20 at 10:05 AM, Infection Control Nurse (ICN) #66 verified there was no evidence to indicate the facility made an attempt to determine if the Resident had been offered or administered the PPSV23 vaccine. ICN #66 stated the facility had no process or procedure in place for monitoring the provision of both vaccines (PPSV23 and PCV13 vaccines) and said, I didn't know there were two vaccines and they both had to be given. Review of the facility's Pneumococcal Vaccine (Series) policy implemented on 11/27/17, stated the type of pneumococcal vaccine will be offered to Residents in accordance with current CDC guidelines and recommendations. The policy further stated: Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received. b) Resident #20 Record review indicated Resident #20, [AGE] years of age, was administered 13-valent pneumococcal conjugate vaccine (PCV13) vaccine on 08/17/16. No documentation was found to indicate the resident either received the 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23) or did not receive the vaccine due to medical contraindications, previous vaccination, or refusal. During an interview on 02/12/20 at 10:05 AM, Infection Control Nurse (ICN) #66 verified there was no evidence to indicate the facility made an attempt to determine if the Resident had been offered or administered the PPSV23 vaccine. ICN #66 stated the facility had no process or procedure in place for monitoring the provision of both vaccines (PPSV23 and PCV13 vaccines) and said, I didn't know there were two vaccines and they both had to be given. Review of the facility's Pneumococcal Vaccine (Series) policy implemented on 11/27/17, stated the type of pneumococcal vaccine will be offered to Residents in accordance with current CDC guidelines and recommendations. The policy further stated: Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received.",2020-09-01
248,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,552,D,0,1,DBDN11,"**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 #50 was afforded the opportunity to be informed of, and participate in, his treatment while a resident at the facility. This was true for one (1) of two (1) residents reviewed for the care area of Language and communication during the long-term care survey process. Resident identifier: #50. Facility census: 65. Findings included: a) Resident #50 A review of Resident #50's medical record, at 8:27 a.m. on 02/26/19, found Resident #50 had two (2) admissions to the facility since 05/01/18. Resident #50 was admitted to the facility on [DATE] and was discharged to home on 08/06/18. He was then readmitted to the facility on [DATE] and is currently still residing in the facility at the time of this review. Further review of the record found two (2) physician's determination of capacity forms. The first form was completed by Resident #50's attending physician on 05/18/18 and was the capacity form in effect from 05/18/18 until his discharge home on 08/06/18. Review of this form found Resident #50's attending physician indicated Resident #50 lacked capacity to make medical decisions. The reason given for this decision by the attending physician read as follows, Significant barrier to communication d/t (due to) thick accent/limited English use. The second capacity statement was completed by Resident #50's attending physician on 01/04/19 and was the current capacity statement in effect at the time of this review it indicated Resident #50 lacked capacity to make medical decisions due to inability to process information, delusions, hallucinations, and dementia secondary to Parkinson disease. Further review of Resident #50's medical record found Resident #50 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated he was cognitively intact. The medical record contained no indication he had a [DIAGNOSES REDACTED]. A review of a physician's progress note completed on 01/4/19, the same day the physician completed the capacity statement found the following, Orientation: Normal - Alert and orientated X 2. Affect is broad. Thought processes are intact. No visible signs of anxiety or depressed state. An interview with the Social Worker at 9:24 a.m. on 02/26/19 confirmed Resident #50 scored a perfect score on the BIMS. She stated, There is nothing wrong with his memory. She stated, I can understand him, and he can understand me. Some people have trouble understanding him, but I don't. She indicated, she did not know why the physician had taken his capacity to make medical decisions away from him and felt it should be reevaluated. She stated, He is sharp as a tack and does not appear to have any dementia problems. She indicated she was not aware that he could not make his own medical decisions. An interview with the Director of Nursing (DON), at 1:14 p.m. on 02/26/19, confirmed Resident #50 was deemed incapacitated by the attending physician on 05/18/18 and again on 01/04/19. She indicated she did not know why the attending physician completed the capacity statements in this manner and indicated she would have him to review Resident #50 for capacity. An interview with the Nursing Home Administrator, on 02/27/19 at 7:45 a.m., confirmed Resident #50's attending physician was at the facility on 02/26/19 in the evening hours and evaluated Resident #50's capacity status. She stated, He (referring to the attending physician) stated Resident #50 had capacity and that he had just made a mistake because it was hard for him to understand Resident #50 due to the fact Resident #50 spoke Spanish. She later provided a new completed capacity form completed by the attending physician on 02/27/19 that indicated Resident #50 had capacity to make medical decisions.",2020-09-01
249,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,561,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, staff interview and family interview, the facility failed to ensure one (2) of two (2) residents reviewed for the care area of choices, had the opportunity to participate in their usual daily routine for dining. Resident #6 was not offered a choice to get up in chair and attend lunch in the atrium. Resident #47 did not get the choice to sleep in and have breakfast served at her preferred time. Resident identifiers: #6, #47. Facility census: 65. Findings included: a) Resident #6 On 02/25/19 at 12:30 PM Resident was observed setting in bed eating lunch. Resident's Medical Power of Attorney (MPOA) was present at bedside and stated that Resident was usually up in chair by now and eats her lunch in the dining hall. MPOA said she had just questioned Nurse Aide (NA) #12 as to why Resident was not up in a chair or eating in dining hall. NA #12 informed MPOA that she did not have enough help to get Resident up with lift. During an interview with Resident #6, on 02/25/19 at 12:35 PM, Resident #6 expressed her personal preference was to be up in chair after breakfast and to go to the atrium to eat her lunch. Resident stated it took two (2) people to get her up, and this morning they were too busy to get her up. At 11:08 AM on 02/26/19 during an interview NA #12 stated, When I have hall 26-30, I never have help, restorative was supposed to help but they usually don't. Yesterday I couldn't find anybody to help me get her (Resident #6) up and it takes two people for the lift. She is usually up in chair by 10:00 and goes to dining hall for lunch. When I work that hallway (Rooms 26-30) I am usually by myself. NA #12 verified that being up chair by mid-morning prior to lunch was the Resident's personal preference and part of her usual daily routine. During an interview, on 02/27/19 at 8:26 AM, Director of Nursing (DON) stated that NA #6, who was assigned to care for Resident #6 was assigned with a restorative aid for assistance. DON specified NA #6 should have found the restorative aide and asked for her for help with resident transfer from bed to chair, and that not having anyone to help her should not have made this an issue. Record Review revealed pulmonology consult dated 01/16/19 listed an intervention in Resident #6's plan of care for her to be out of the bed to the chair every day. b) Resident #47 During an interview with the resident's responsible party (RP) at approximately 3:15 PM on 02/25/19, the RP said the resident always liked to sleep in and have breakfast around 10:00 AM when she was at home. The RP felt staff woke the resident up too early which made her combative. The RP said, Staff don't listen to me when I try to tell them to give her breakfast at 10:00 and don't wake her up so early. Staff want to get her up at 5:00 AM so she can eat at 7:00 AM. Review of the nursing notes found the following entry: 2/15/2019 08:21 Care Plan Note: Annual Care conference held on 2/13/19. No Nursing concerns noted. Nursing reports that Medication review by pharmacy was completed in (MONTH) 2019 with no medication recommendations. No Activity concerns noted, Resident continues to participate well and remains very social. Discussed information provided by Director of Dietary, (name of dietary manager); Resident is currently on a mechanical soft diet eating an average of 76-100% of meals with her weight remaining stable. Reviewed CNA (certified nursing assistant) Reports: Resident does not like to get up in the mornings and can be quite grumpy at times and at times refusing her breakfast tray, but once up she is pleasant. Resident's POA (power of attorney) states that all you can do is encourage her to get up and eat breakfast say that she can lay back down when finished if she wants. She also states that Resident prefers to not get up until around 10 am. Social Worker reviewed advance directives, preferences for care. No issues or concerns noted. Care Plan reviewed. Review of the Resident's current care plan found the problem: Risk of altered nutrition/hydration status related to cognitive deficits related to dementia and [DIAGNOSES REDACTED]. A goal associated with the problem was: Resident will consume 51% or greater at most meals through next review. Interventions included: Resident prefers to wait until 10:00 AM or after for breakfast. At 8:36 AM on 02/26/19 08:36 AM, the resident's nursing assistant (NA) #12 was interviewed. NA #12 said the breakfast trays came out around 7:00 AM. She said the resident was served breakfast, but she didn't eat anything. NA #12 said the trays have already been picked up. Observation of the resident at 10:00 AM on 02/26/19, found she was in her room sitting in her wheelchair watching television. Continued observation of the resident found she did not receive a tray. At 10:19 AM on 02/26/19, the food service director, (FSD) #39 was asked if Resident #47 received a tray at 10:00 AM. FSD replied, We don't cook a meal at 10:00 AM. She said if the resident was hungry, she could ask for some food items from the, always available menu, and the kitchen staff would get her something to eat. Review of the resident's most recent minimum data set (MDS), an annual, with an assessment reference date (ARD) of 01/21/19 found the resident scored a 7 on her brief interview for mental status (BIMS). A score of 7 indicates the resident's cognition is severely impaired. At 11:15 AM on 02/26/19, the administrator said the resident can have a tray at 10:00 AM if she wants one. The resident's BIMS score was discussed with the administrator. The administrator verified that most likely the resident could not advise staff it was 10:00 AM and she wanted a breakfast tray with a BIMS score of 7. The administrator said she would take care of the situation and the resident could receive breakfast at 10:00 AM from now on.",2020-09-01
250,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,576,C,0,1,DBDN11,"Based on resident interview and staff interview, the facility failed to ensure residents had the right to receive mail on Saturdays when delivery was available through the postal service. This had the potential to affect all residents residing at the facility. Facility census: 65. Findings included: a) Resident council meeting At 2:15 PM on 02/26/19, residents attending the council meeting were asked the question, is mail delivered unopened and on Saturdays? The residents agreed their mail was unopened, but they didn't know if mail was delivered on Saturdays. The activity director (AD) #10 attended the meeting. The AD said the facility did not get mail on Saturdays. She did not know if the mail could be delivered. On 02/27/19 at 3:46 PM, the administrator said the mail hadn't been delivered on Saturdays. The administrator contacted the postal carrier who can deliver mail on Saturdays and mail delivery has been arranged.",2020-09-01
251,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,622,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure documentation regarding the specific reason for the transfer on the Notice of Discharge or Transfer was provided to the guardian and ombudsman for one (1) of one (1) residents reviewed for the care area of hospitalization . Additionally, the physician did not document the reason for the resident's transfer. Resident identifier: #70. Facility census: 65. Findings included: a) Resident #70 Review of Resident #70's medical records revealed an emergency transfer to the hospital on [DATE] at 2:15 AM. The reason for the transfer according to the medical records was, Resident physically struck roommate, causing unsafe environment. A Notice of Transfer of Discharge was completed on 12/31/18. The Notice of Transfer or Discharge stated, Due to the reason indicated below a discharge or transfer from this center will be necessary. - The transfer or discharge is appropriate because your health has improved sufficiently that you no longer need the services provided by this center. - The transfer or discharge is necessary for your welfare and your needs cannot be met in this center. - The safety of other individuals in this center is endangered. - The health of other individuals in this center is endangered. Each of the discharge or transfer reasons had a box before the item that could be checked as appropriate. None of the reasons for discharge or transfer had been checked. The Notice of Transfer or Discharge stated Resident #70's guardian was verbally notified on 12/31/18. The time of notice was not given. A facsimile communication report showed the Notice of Transfer or Discharge was sent to the ombudsman on 01/18/19. No physician documentation regarding the reasons for Resident #70's transfer was in the medical records. The resident was ultimately not permitted to return to the facility. During an interview, on 02/27/19 at 12:21 PM, the Director of Nursing (DoN) agreed the reason for Resident #70's transfer or discharge was not indicated on the Transfer or Discharge form. The DoN was also unable to locate documentation by the resident's physician regarding the reason for transfer. During an interview, on 02/27/19 at 3:45 PM, the facility administrator was informed the reason for Resident #70's transfer or discharge was not indicated on the Transfer or Discharge form. She was also informed the physician did not document the reasons for the resident's transfer. She had no further information regarding the matter. No further information was received through the completion of the survey.",2020-09-01
252,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,626,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure physician documentation regarding the reason the resident was not permitted to return to the facility for one (1) of one (1) residents reviewed for the care area of hospitalization . Additionally, the facility failed to provide written notice to the resident's guardian and to the ombudsman specifically stating the resident would not be permitted to return to the facility. Resident identifier: #70. Facility census: 65. Findings included: a) Resident #70 Review of Resident #70's medical records revealed an emergency transfer to the hospital on [DATE] at 2:15 AM. The reason for the transfer according to the medical records was, Resident physically struck roommate, causing unsafe environment. A nursing note written at 12/31/2018 at 12:45 PM stated, This nurse called facility medical director, (physician name) regarding resident's status in facility pending return from hospital. (Physician name) expressed to this nurse that he did not feel comfortable accepting him back because he felt that the resident has had an increase in combative behavior and feels that we have to take into consideration our other resident's well-being. He feels that this resident may be a danger to other resident's going forward. It is also his belief that he requires more care than we are able to provide. At this time, we are unable to meet his needs and he will not accept him back in facility as a resident. A nursing note, written on 12/31/2018 at 1:20 PM stated, (Guardian name), guardian notified by this nurse that (physician name) has decided to not accept this resident back into this facility as he feels that this resident requires more care than we can provide. (Resident's name's) ongoing increase in behaviors towards staff and other resident's places the safety of our resident's at risk. It was explained that we had to take into account the safety of all residents at this time and in doing so, he cannot return. A Notice of Transfer of Discharge was completed on 12/31/18. The Notice of Transfer or Discharge stated, Due to the reason indicated below a discharge or transfer from this center will be necessary. - The transfer or discharge is appropriate because your health has improved sufficiently that you no longer need the services provided by this center. - The transfer or discharge is necessary for your welfare and your needs cannot be met in this center. - The safety of other individuals in this center is endangered. - The health of other individuals in this center is endangered. Each of the discharge or transfer reasons had a box before the item that could be checked as appropriate. None of the reasons for discharge or transfer had been checked. The Notice of Transfer or Discharge gave the effective date of transfer as 12/31/18. The destination of transfer was a local hospital's emergency room . The Notice of Transfer or Discharge stated Resident #70's guardian was verbally notified on 12/31/18 the time of notice was not given. A facsimile communication report showed the Notice of Transfer or Discharge was sent to the ombudsman on 01/18/19. During an interview, on 02/27/19 at 10:52 AM, Medical Records Clerk #35 stated she was unable to locate written information to Resident #70's guardian or to the ombudsman specifically stating the resident would not be permitted to return to the facility. Medical Records Clerk #35 was also unable to locate physician documentation regarding the reason Resident #70 would not be permitted to return to the facility. She stated no physician discharge summary was completed because Resident #70 was transferred to the hospital instead of discharged . During an interview on 02/27/19 at 12:21 PM, the Director of Nursing (DoN) stated the only notice provided to Resident #70's guardian and the ombudsman was the afore-mentioned Notice of Transfer or discharge date d 12/31/18. The DoN was unable to locate written information to the guardian and ombudsman specifically stating the resident would not be permitted to return to the facility. She was also unable to locate documentation by Resident #70's physician stating the reasons the resident would not be permitted to return to the facility. During an interview, on 02/27/19 at 3:45 PM, the facility administrator was informed Resident #70's guardian and the ombudsman were not provided written information specifically stating the resident would not be returning to the facility. The administrator was also informed Resident #70's physician did not document the reasons the resident would not be permitted to return to the facility. The administrator had no further information regarding the matter. No further information was received through the completion of the survey.",2020-09-01
253,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,641,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and observation, the facility failed to ensure the accurate completion of the Minimum Data Set (MDS) for Resident #69 in the area of prognosis, for Resident #23 in the area of dental and prognosis, and Resident #68 in the area of discharge/return to the community. This was true for three (3) of 16 MDSs reviewed during the long term care survey. Resident Identifiers: #69, #23, and #68. Facility Census: 65. Findings included: a) Resident #69 A review of Resident #69's medical record, on 02/26/18 at 10:32 AM, found Resident #69 was admitted to hospice services on 09/25/18. A review of a signficant change MDS with an Assessment Reference Date (ARD) of 09/29/18 found Section J1400 Prognosis was marked to indicate Resident #69 did not have a condition or chronic disease that would result in a life expectancy of less than 6 months. This was not accurate considering Resident #69 was admitted to hospice services on 09/25/18. An interview with the MDS Coordinator Registered Nurse (RN) #66, at 3:00 PM on 02/27/19, confirmed this section was coded incorrectly. She stated, Since she was a hospice resident this should have ben marked yes not no. b) Resident #23 1. Dental Observations of Resident #23, on 02/25/19 at 1:58 PM, found Resident #23 was edentulous. She was observed sitting in her Geri- Chair in her with her mouth open. Her entire mouth could be observed and there were no teeth in her mouth. A review of Resident #23's medical record, at 1:12 PM on 02/26/19, found on 08/27/18 Resident #23 was assessed as having no natural teeth. Review of a Signficant Change MDS with an Assessment reference date (ARD) 09/18/18 found Section L Oral/Dental Status L Dental was marked Z. None of the above were present. This indicated Resident #23 had no dental problems. This was inaccurate and should have been marked B. No natural teeth or tooth Fragments (edentulous) . An interview with the MDS Coordinator Registered Nurse (RN) #66, at 3:00 PM, on 02/27/19 confirmed this section was coded incorrectly. She agreed B should have been marked since Resident #23 was edentulous. 2. Prognosis A review of Resident #23's medical record at 1:12 p.m. on 02/26/19 found Resident #23 was admitted to hospice services on 09/14/18. Review of a Signficant Change MDS with an ARD 09/18/18 found section J1400. Prognosis was marked to indicate Resident #23 did not have a condition or choric disease that may result in a life expectancy of less than 6 months. This was not accurate considering Resident #23 was admitted to hospice services on 09/14/18. An interview with the MDS Coordinator Registered Nurse (RN) #66 at 3:00 p.m. on 02/27/19 confirmed this section was coded incorrectly. She stated, Since she was a hospice resident this should have ben marked yes not no. c) Resident #68 Record review found Resident #68 was admitted to the facility on [DATE]. Upon admission, he expected to return home and discharge planning was initiated. The resident returned home on 12/15/18. Review of the resident's admission MDS with an ARD of 11/7/18, found the resident expected to return to the community after his nursing home stay. The MDS indicated the resident participated in answering questions regarding discharge to home and his expectations. A question on the MDS asks if the resident wanted to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community. The question was to be answered by checking one of the following: Yes, no, or unknown or uncertain. The facility checked unknown or uncertain. Directions from the ARI Manual: Code 0, No: if the resident (or family or significant other, or guardian or legally authorized representative) states that he or she does not want to talk to someone about the possibility of returning to live and receive services in the community. Code 1, Yes: if the resident (or family or significant other, or guardian or legally authorized representative) states that he or she does want to talk to someone about the possibility of returning to live and receive services in the community. Code 9, Unknown or uncertain: if the resident cannot understand or respond and the family or significant other is not available to respond on the resident ' s behalf and a guardian or legally authorized representative is not available or has not been appointed by the court. Resident #68 was alert, oriented, and had capacity to make medical decisions. The resident scored a 15 on his brief interview for mental status (BIMS). A score of 15 is the highest score obtainable and indicates the resident has cognition is intact. On 02/26/19 at 4:00 PM, the facility social worker, the author of the MDS, verified the MDS was coded incorrectly.",2020-09-01
254,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,656,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to implement a care plan for one (1) of sixteen (16) residents whose care plans were reviewed. Resident #47's care plan regarding her morning meal preference time was not implemented. Resident identifier: #47. Facility census: 65. Findings included: a) Resident #47 During an interview with the resident's responsible party (RP), at approximately 3:15 PM on 02/25/19, the RP said the resident always liked to sleep in and have breakfast around 10:00 AM when she was home. The RP felt staff woke the resident up too early which made her combative. The RP said, Staff don't listen to me when I try to tell them to give her breakfast at 10:00 and don't wake her up so early. Staff want to get her up at 5:00 AM so she can eat at 7:00 AM. Review of the nursing notes found the following entry: 2/15/2019 08:21 Care Plan Note Note : Annual Care conference held on 2/13/19. No Nursing concerns noted. Nursing reports that Medication review by pharmacy was completed in (MONTH) 2019 with no medication recommendations. No Activity concerns noted, Resident continues to participate well and remains very social. Discussed information provided by Director of Dietary, (name of dietary manager); Resident is currently on a mechanical soft diet eating an average of 76-100% of meals with her weight remaining stable. Reviewed CNA (certified nursing assistant) Reports: Resident does not like to get up in the mornings and can be quite grumpy at times and at times refusing her breakfast tray, but once up she is pleasant. Resident's POA (power of attorney) states that all you can do is encourage her to get up and eat breakfast say that she can lay back down when finished if she wants. She also states that Resident prefers to not get up until around 10am. Social Worker reviewed advance directives, preferences for care. No issues or concerns noted. Care Plan reviewed. Review of the Resident's current care plan found the problem: Risk of altered nutrition/hydration status related to cognitive deficits related to dementia and [DIAGNOSES REDACTED]. A goal associated with the problem was: Resident will consume 51% or greater at most meals through next review. Interventions included: Resident prefers to wait until 10:00 AM or after for breakfast. At 8:36 AM on 02/26/19 08:36 AM, the resident's nursing assistant, (NA) #12 was interviewed. NA #12 said the breakfast trays came out around 7:00 AM. She said the resident was served breakfast but she didn't eat anything. NA #12 said the trays had already been picked up. Observation of the resident at 10:00 AM on 02/26/19, found she was in her room sitting in her wheelchair watching television. Continued observation of the resident found she did not receive a tray. At 10:19 AM on 02/26/19, the food service director, (FSD) #39 was asked if Resident #47 received a tray at 10:00 AM. FSD replied, We don't cook a meal at 10:00 AM. She said if the resident was hungry she could ask for some food items from the, always available menu, and the kitchen staff would get her something to eat. Review of the resident's most recent minimum data set (MDS), an annual, with an assessment reference date (ARD) of 01/21/19 found the resident scored a (7) on her brief interview for mental status (BIMS). A score of 7 indicated the resident's cognition was severely impaired. At 11:15 AM on 02/26/19, the administrator said the resident could have a tray at 10:00 AM if she wanted one. The resident's BIMS score was discussed with the administrator. The administrator verified that most likely the resident could not advise staff it was 10:00 AM and she wanted a breakfast tray with a BIMS score of 7. The administrator said she would take care of the situation and the resident could receive breakfast at 10:00 AM from now on.",2020-09-01
255,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,684,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to administer medication in accordance with physician orders. This was a random opportunity for discovery. The facility did not obtain the resident's pulse or systolic blood pressure before administering the beta-blocker, [MEDICATION NAME]. Resident identifier: #47. Facility census: 65. Findings included: a) Resident #47 Medical record review found a physician's orders [REDACTED]. Systolic is the first number of the resident's blood pressure. Systolic blood pressure, measures the pressure in your blood vessels when your heart beats. The order was effective on 12/29/18. [MEDICATION NAME] is a beta-blocker. Beta-blockers affect the heart and circulation. [MEDICATION NAME] is used to treat heart failure and hypertension. Review of the resident's medication administration (MAR) for (MONTH) (YEAR), (MONTH) 2019, and (MONTH) 2019, found the medication was given daily; however, there was no evidence staff obtained the resident's pulse or blood pressure before administering the medication. On 02/26/19 at 9:05 AM, the director of nursing (DoN) verified staff would not know if the resident's medication should be held if pulse and systolic blood pressure were not obtained before administration. The DoN said staff should record the pulse on the MAR. The DoN was unable to provide verification the physician's orders [REDACTED].",2020-09-01
256,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,745,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #50 was provided medically-related social services to enable him to attain and/or maintain his highest practicable physical, mental and psychosocial well-being. This was true for one (1) of two (2) residents reviewed for the care area of communication during the long-term care survey. Resident identifier: #50. Facility census: 65. Findings included: a) Resident #50 A review of Resident #50's medical record at 8:27 a.m. on 02/26/19 found Resident #50 had two (2) admissions to the facility since 05/01/18. Resident #50 was admitted to the facility on [DATE] and was discharged to home on 08/06/18. He was then readmitted to the facility on [DATE] and is currently still residing in the facility at the time of this review. Further review of the record found two (2) physician's determination of capacity forms. The first form was completed by Resident #50's attending physician on 05/18/18 and was the capacity form in effect from 05/18/18 until his discharge home on 08/06/18. Review of this form found Resident #50's attending physician indicated Resident #50 lacked capacity to make medical decisions. The reason given for this decision by the attending physician read as follows, Significant barrier to communication d/t (due to) thick accent/limited English use. The second capacity statement was completed by Resident #50's attending physician on 01/04/19 and was the current capacity statement in effect at the time of this review it indicated Resident #50 lacked capacity to make medical decisions due to inability to process information, delusions, hallucinations, and dementia secondary to Parkinson disease. Further review of Resident #50's medical record found Resident #50 had a Brief Interview of Mental Status (BIMS) score of 15 which indicates he is cognitively intact. The medical record contained no indication he had a [DIAGNOSES REDACTED]. In fact, a review of a physician's progress not completed on 01/4/19 the same day he completed the capacity statement found the following, Orientation: Normal - Alert and orientated X 2. Affect is broad. Thought processes are intact. No visible signs of anxiety or depressed state. An interview with the Social Worker at 9:24 a.m. on 02/26/19 confirmed that Resident #50 scored a perfect score on his brims. She stated, There is nothing wrong with his memory. She stated I can understand him, and he can understand me. Some people have trouble understanding him, but I don't She indicated, she did not know why the physician had taken his capacity to make medical decisions away from him and felt it should be reevaluated. She stated, He is sharp as a tack and does not appear to have any dementia problems. She indicated she was not aware that he could not make his own medical decisions. An interview with the Director of Nursing (DON) at 1:14 p.m. on 02/26/19 confirmed Resident #50 was deemed incapacitated by the attending physician on 05/18/18 and again on 01/04/19. She indicated she did not know why the attending physician completed the capacity statements in this manner and indicated she would have him to review Resident #50 for capacity. An interview with the Nursing Home Administrator on 02/27/19 at 7:45 a.m. confirmed Resident #50's attending physician was at the facility on 02/26/19 in the evening hours and evaluated Resident #50's capacity status. She stated, He (referring to the attending physician) stated Resident #50 has capacity and that he had just made a mistake because it was hard for him to understand Resident #50 due to the fact Resident #50 spoke Spanish. She later provided a new completed capacity form completed by the attending physician on 02/27/19 that indicated Resident #50 had capacity to make medical decisions.",2020-09-01
257,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,757,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #62's drug regimen was free from unnecessary medications. Resident #62 received three (3) excessive doses of an antibiotic. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications during the long term care survey process. Resident identifier: 62. Facility census: 65. Findings included: a) Resident #62 A review of Resident #62's medical record, at 9:21 AM on 02/27/19, found a physician's orders [REDACTED]. This order had a start date of 02/04/19. A review of Resident #62's Medication Administration Record [REDACTED]. Resident #62 was only prescribed 20 doses by her attending physician. An interview with the Director of Nursing (DoN), at 11:16 a.m. 02/27/19, confirmed Resident #62 received three (3) extra doses of Cipro. She stated, It looks like they took the first three (3) doses from the Emergency box and then gave the 20 doses that were ordered from the pharmacy also.",2020-09-01
258,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,842,D,0,1,DBDN11,"Based on record review, observation, and staff interview the facility failed to ensure Resident #23's medical record was complete and accurate. Resident #23 had multiple dental assessments contained in her record that were not accurately completed. This was true for one (1) of 16 sampled residents. Resident identifier: 23. Facility census: 65. Findings included: a) Resident #23 An observation of Resident #23, at 1:58 PM, on 02/27/19 found she edentulous. She was observed sitting in her Geri Chair. Her mouth was opened and could be easily observed. This observation revealed Resident #23 had no teeth. A review of Resident #23's medical record, at 1:12 PM on 02/26/19, found the following dental assessments which were inaccurately completed: 12/18/18 Indicated Resident #23 had no dental problems. 04/01/18 Indicated Resident #23 had no dental problems. 04/26/18 Indicated Resident #23 had no dental problems. 09/23/16 Indicated Resident #23 had no dental problems. An interview with the Director of Nursing on 02/26/19 at 01:50 PM confirmed Resident #23 was edentulous and the above mentioned assessments should have been marked to indicate this, but they were not.",2020-09-01
259,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,565,E,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, record review and staff interview, the facility failed to respond to a group grievance concerning the water pitches in a timely manner. This failed practice had the potential to affect more than an isolated number. Facility census: 56. Finding included: a) Resident council meeting On 11/21/17 the resident council filed a Concern/Grievance Form concerning the water pitchers not returned to them in a timely manner. The investigation completed on 11/27/18 stated, Audit was done to see if all residents had water pitchers. We noted during audit that there was a shortage of water pitchers. This was taken care of immediately. Extra water pitchers were ordered by dietary department. The date of the complaint resolution as left blank. During an interview on 03/12/18 at 10:49 AM, Resident # 28 said, We don't have anyway to keep ice and water in the rooms, we used to. It stopped when a new company took over and they stopped using the plastic pitchers and now are using these old Styrofoam cups. They don't hold much or keep the water very cold long, plus it is hard to hold. She demonstrated that she can not hold the cup very easy. She said she and others have request to get the pitchers back sometime ago but they did not get them back. On 03/13/18 at 01:30 PM, DON said about two weeks ago they started using Styrofoam cups, but have already ordered new pitchers to replace the others because they kept disappearing. She said the Food Service Manager had ordered some new ones. She was shown the resident council meeting minutes, which was in (MONTH) 21, (YEAR) concerning a complaint about not having any pitchers, she said they had not been worried about because they were worried about getting ready for the surveyors. During an interview on 03/13/18 at 01:45 PM, Food Service Manager #20 said about a month ago nursing asked if they could change from the pitchers to throw cups. No order order has been made because he was unaware of the change back to pitcher. He state he was not sure if he knew about the the complaints in (MONTH) council meeting about the pitchers. On 03/13/18 at 03:45 PM, the Administrator said the pitcher thing is a miscommunication between dietary and nursing. They ordered new pitchers in (MONTH) when the residents complained, but had a flu problem in January, so for infection control they were using disposable cups. Records indicated that the residents were given [MEDICATION NAME] on 01/28/18. She said she could provide a receipt to show the pitches were ordered in November, but the only receipt that was shown was dated 03/13/18 at 02:18 PM, for new pitchers. On 03/13/18 at 04:10 PM, she said they found 60 pitchers and all residents will have a water pitcher in the morning.",2020-09-01
260,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,641,D,0,1,YXUB11,"**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 four (4) resident's reviewed for the care area of nutrition had an accurate and complete minimum data set (MDS). This failed practice had the potential to affect a limited number of residents. Resident identifier: #40. Facility census: 56. Findings included: a) Resident #40 Record review on 03/13/18 at 11:00 AM, found the resident was admitted to the facility on [DATE]. The residents first weight was recorded as 271.3 pounds on 10/06/17. A significant change in status MDS with an assessment reference date (ARD) of 02/01/18, noted the resident's current weight was 221 pounds. The MDS coded the resident as having no weight loss, (5% or more in the last month or loss of 10% or more in last 6 months.) An interview with the dietary manager (DM) #20, at 12:14 PM on 03/13/18, confirmed the resident had an actual weight loss of 18.54 % as calculated by dietary manager at the time of the MDS with an ARD of 02/01/18. The DM verified the MDS was coded incorrectly.",2020-09-01
261,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,656,D,0,1,YXUB11,"**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 one (1) of four (4) residents reviewed for the care area of nutrition had a measurable care plan to address fluid intake. In addition, one (1) of three (3) residents reviewed for pressure ulcers failed to have interventions in place, as directed by the care plan, to promote healing of existing pressure ulcers and/or prevent the development of new pressure ulcers. Resident identifiers: #40 and #26. Facility census: 56. Findings included: a) Resident #40 Review of the resident's current care plan, dated 01/03/18, found the following focus/problem: --Risk of altered nutrition/hydration status related to inadequate intake of food and fluids. A goal associated with the problem was: --Resident will remain free of sign/symptoms of dehydration such as sunken eyes, decreased urine output, dry mucous membranes, daily through next review. A second care plan focus/problem, dated 03/12/18: --Resident has a urinary tract infection. The goal associated with the problem: --Resident's urinary tract infection will resolve with no complication. Interventions included: --Encourage fluids as tolerated. A comprehensive nutritional assessment, completed by the registered dietician on 01/26/18, noted the resident required 2070 milliliters of fluid a day. At 2:45 PM on 03/14/18, the director of nursing (DON) verified the facility did not keep any records to determine how much fluids any residents may or may not have consumed during the day. The facility only records the percent of food consumed by residents in a day. She was unable to verify how the facility determined the resident had an inadequate intake of fluids as specified on the care plan or how the facility would monitor daily fluid intake to ensure the resident consumed the required milliliters of daily fluid. The resident also had a urinary tract infection and the DON confirmed the facility could not verify fluids were encouraged as stated on the care plan. b) Resident #26 Review of the care plan, dated 02/12/18, found the current problem/focus: --Resident has or was admitted with pressure injuries to left inner foot, right gluteal fold, unstageable to right outer foot, and blanchable reddened area to right lateral foot, Deep tissue pressure injury to left inner heel. Potential for further pressure injury related to diabetes mellitus, [MEDICAL CONDITION] with bilateral leg contractures, recurrent hip dislocation, chronic pain, [MEDICAL CONDITION] requiring transfusion, hypertension, [MEDICAL CONDITION], dry skin and scalp, [MEDICAL CONDITION] and muscle wasting. Including the following pressure ulcers: --Stage 4 pressure ulcer to the right (middle) outer foot --Stage 2 pressure ulcer to the left buttock --Resolved Stage 2 pressure ulcer to the left elbow --Unstageable pressure ulcer to the right outer foot (distal, below little toe) The goal associated with the focus/problem: --Resident will have no further pressure ulcer formation noted through next review period. Interventions included: --May use knee/ankle abductor cushion between knees to help prevent further skin breakdown, --Resident will have elbows heels floated as allowed by the resident while in bed. Observation of the resident with the director of nursing (DON) at 1:57 p.m. on 03/13/18, found the resident did not have the abductors on and did not have elbows/heels floated as directed by the care plan. When asked why he did not have the abductors on, the resident said, I had them on earlier, they took them off when they pulled me up in the bed and didn't put them back on. At 2:06 p.m. on 03/13/18, the DON confirmed the resident's care plan addressing pressure ulcers was not followed as written.",2020-09-01
262,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,657,D,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the comprehensive care plan was revised in the area of nutrition for one (1) of four (4) residents reviewed for the care area of nutrition. This failed practice had the potential to affect a limited number of residents. Resident identifier: #5. Facility census: 56. Findings included: a) Resident #5 Resident #5 had an order written [REDACTED]. This order was discontinued on 10/25/17 because the resident preferred a different nutritional supplement. Review of Resident #5's comprehensive care plan on 03/13/18 revealed the focus of Risk of altered nutrition/hydration status related to inadequate intake of food and fluids contained the intervention of 2-cal, 60 ml, twice a day. During an interview on 03/13/18 at 1:07 PM, the Director of Nursing (DON) was informed Resident #5's comprehensive care plan continued to include the intervention of 2-cal, 60 ml, twice a day even though this nutritional supplement had been discontinued 10/15/17. The DoN had no further information regarding this matter.",2020-09-01
263,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,684,D,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to follow physician orders [REDACTED]. This failed practice had the potential to affect a limited number of residents. Resident identifier: #5. Facility census: 56. Findings included: a) Resident #5 Resident #5 had an order written [REDACTED]. Medication side effects were ordered to be monitored. Review of Resident #5's Medication Administration Record [REDACTED]= SE and 2 = No SE. However, side effects had not been monitored. Resident #5 was also prescribed another medication, [MEDICATION NAME], for depression and appetite stimulation. The resident was also to be monitored for side effects of [MEDICATION NAME]. The MAR indicated [REDACTED]. However, the MAR indicated [REDACTED]. During an interview on 03/13/18 at 1:07 PM, the Director of Nursing (DoN) was informed physician's orders [REDACTED].#5 for side effects of [MEDICATION NAME] was not followed in March, (YEAR). The DoN had no further information regarding this matter.",2020-09-01
264,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,686,D,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review and staff interview, the facility failed to provide care and services to promote the healing of existing pressure ulcers and prevent development of additional pressure ulcers for one (1) of three (3) residents reviewed for the care area of pressure ulcers. Resident #26 did not have pressure relieving devices in place as directed by the care plan. Resident identifier: #26. Facility census: 56. Findings include: a) Resident #26 Review of the care plan, dated 02/12/18, found the current problem/focus: --Resident has or was admitted with pressure injuries to left inner foot, right gluteal fold, unstageable to right outer foot, and blanchable reddened area to right lateral foot, Deep tissue pressure injury to left inner heel. Potential for further pressure injury related to diabetes mellitus, [MEDICAL CONDITION] with bilateral leg contractures, recurrent hip dislocation, chronic pain, [MEDICAL CONDITION] requiring transfusion, hypertension, [MEDICAL CONDITION], dry skin and scalp, [MEDICAL CONDITION] and muscle wasting. Including the following pressure ulcers: --Stage 4 pressure ulcer to the right (middle) outer foot --Stage 2 pressure ulcer to the left buttock --Resolved Stage 2 pressure ulcer to the left elbow --Unstageable pressure ulcer to the right outer foot (distal, below little toe) The goal associated with the focus/problem: --Resident will have no further pressure ulcer formation noted through next review period. Interventions included: --May use knee/ankle abductor cushion between knees to help prevent further skin breakdown, --Resident will have elbows heels floated as allowed by the resident while in bed. Observation of the resident with the director of nursing (DON) at 1:57 PM on 03/13/18, found the resident did not have the abductors on and did not have elbows/heels floated as directed by the care plan. When asked why he did not have the abductors on the resident said, I had them on earlier, they took them off when they pulled me up in the bed and didn't put them back on. At 2:06 pm on 03/13/18, the DON confirmed the resident's care plan was not being followed as written. On 03/14/18 at 12:56 PM the absence of the devices, knee/ankle abductor and the floating of the elbows and heels were again discussed with the DON. The resident has a history of pressure ulcer development and healing since his admission to the facility on [DATE]. The DON confirmed these devices were implement to prevent future skin breakdown and promote the healing of existing pressure ulcers.",2020-09-01
265,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,692,D,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, observation, and staff interview, the facility failed to recognize, evaluate, and address the nutritional needs of one (1) of four (4) residents reviewed for the care area of nutrition. In addition, the facility failed to to ensure proper hydration was provided to one resident during a random opportunity for discovery. Resident identifiers: #40 and #30. Facility census: 56. Findings included: a) Resident #40 During an interview with the resident on 03/12/18 at 10:12 AM, she said, I get mashed potatoes for every meal, I don't know why they can't fortify something else-like some macaroni and cheese for a change. The resident said she was losing weight because she can not eat and the food is not good. Record review found the resident was admitted to the facility on [DATE]. The resident's weight was recorded as 271.3 pounds on 10/06/17. The last weight recorded was 219 pounds on 03/12/18. A 19.28% weight loss since admission. Review of the resident's current care plan, dated 01/03/18, found the following focus/problem: Risk of altered nutrition/hydration status related to inadequate intake of food and fluids. A goal associated with the problem was: --Resident will remain free of sign/symptoms of dehydration such as sunken eyes, decreased urine output, dry mucous membranes, daily through next review. Interventions included: --Dietary to provide fortified foods one item per tray, initiated on 01/24/18, --Honor food preferences, --Dietary to provide 8 ounces of whole milk with meals, yogurt at 2pm and 1/2 sandwich hs (at night time) Two comprehensive nutritional assessments were completed by the registered dietician (RD) since the resident's admission. On on 10/07/17 and 01/29/18. On 10/07/17, the nutrition summary noted: --New admission. [AGE] year old female .BMI (body mass index) indicates obesity; no interventions warranted due to diagnosis. Will allow resident time to adjust to facility, encourage po (by mouth) intake, and monitor weights per policy .Weight fluctuations may occur due to diuretic . Weight loss meetings were held, on 12/01/17 and 01/12/18. --12/01/17, Weight meeting held with IDT (interdisciplinary team) members. Weight loss trend continues. PO intake 51-75% of most meals. RD recommendations reviewed 11/30/17 and new order received for house shake BID. Currently receiving whole milk with meals, yogurt daily and 1/2 sandwich at QHS. Resident has a [DIAGNOSES REDACTED]. --01/12/18, Weight meeting held with IDT members. Resident has [DIAGNOSES REDACTED].Several interventions in place including whole milk with meals, yogurt daily at 2 pm per request. HS snack of choice, handmade chocolate milkshakes BID (twice a day), one fortified food item per tray . Review of the hospital discharge summary, dated 10/05/17 found the resident has a surgical history of, Laparoscopic gastric banding surgery. (Laparoscopic gastric banding is surgery to help with weight loss. The surgeon places a band around the upper part of your stomach to create a small pouch to hold food. The band limits the amount of food you can eat by making you feel full after eating small amounts of food.) Normally a person with this surgery would need to eat several small meals daily, instead of three (3) large meals per day. The facility physician also noted the resident had Laparoscopic gastric banding surgery on the, New Patient History and Physical. Observation of the resident's noon meal on 03/12/17 found she had chicken and dumplings and mashed potatoes. Observation of the noon meal again on 03/13/17 found the resident had roast beef and mashed potatoes. At 12:14 PM on 03/13/18, the dietary manager verified the resident does have mashed potatoes for every lunch and supper meal-that is the food we fortify. He confirmed the resident only receives fortified oatmeal for breakfast and fortified mashed potatoes with every lunch and supper. He was not aware the resident had said she was tired of mashed potatoes and could no longer eat them. He said he could fortify some macaroni and cheese as requested by the resident. The DM said he is also unaware the resident had lap band surgery and did not know what kind of a diet the resident should receive after having the surgery. He confirmed the facility had never considered the lap band surgery as contributing to the resident's weight loss. At 8:20 AM on 03/14/18, the resident said she was unable to eat large meals at one setting because of her surgery. She said, If I had the right foods, I could eat more. She said she just requested a hot bowl of chicken noodle soup for lunch. That's all I want and it can even be from a can, just a bowl of hot chicken noodle soup. At 8:57 AM on 03/14/18, the resident's weight loss was discussed with the administrator. She was asked if anyone had every considered the resident's Laparoscopic gastric banding as contributing to her weight loss? The administrator was also advised the resident had been receiving mashed potatoes for every lunch and supper since 01/24/18 because the DM said this was the only food item his staff fortified. A third observation of the resident's noon meal at 12:20 PM on 03/14/18, with nursing assistant, NA #91, found the resident received mashed potatoes again. (She did have chicken noodle soup). At 1:16 PM on 03/14/18, the dietary manager was asked why the resident had mashed potatoes again. He stated, my staff only knows how to fortify mashed potatoes, I have to train them to fortify other food items, like the macaroni and cheese-I don't want them to do it the wrong way. Review of the facility's document entitled, Increasing the calorie content of a meal pattern, was reviewed with the DM. Lunch and dinner meals can be [MEDICATION NAME]/fortified with: --Extra margarine to vegetables and starches, serve cheese, cheese sauce, margarine, sour cream on meats, vegetables, or starches; --Offer fortified soup, fortified mashed potatoes or fortified pudding with meals; offer [MEDICATION NAME] milk as a beverage with meals. The DM said those were good ideas for fortifying foods and he would train his staff. At the close of the survey on 03/15/18 at 6:00 PM the facility provided no further information on Resident #40. No information was provided the facility staff addressing the resident's weight loss was aware of the Laparoscopic gastric banding surgery or considered this surgery as contributing to weight loss and attempted to provide a diet that could be tolerated by the resident. b) Resident #30 A random observation of Resident #30 on 03/12/18 at 12:10 PM, found there was no drinks with her lunch and no water pitcher on table or in the room. Resident #30 said, I would like to have had something to drink with my lunch, all I have had today to drink was a shake drink in that little box. On 03/13/18 at 10:00 AM, the director of nursing (DON) was notified about Resident # 30 not having any drinks with the her lunch yesterday. She was asked if she could find her fluid intake for yesterday. She said do not document fluid intake only meal percentages. During an observation on 03/13/18 at 10:24 AM, Resident #30 had a drink on her table. On 03/13/18 at 10:40 AM, the DON said yesterday Resident # 30 didn't get drinks on her tray because her tray was sent to the atrium and the drinks are put on the table not on the tray, but not sure why she was not given anything to drink in her room.",2020-09-01
266,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,757,D,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure Resident #62's medication regimen was free from unnecessary medication. Resident #62 was administered an antihypertensive ([MEDICATION NAME]) medication outside of the physician prescribed parameters. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #62. Facility census: 56. Findings included: a) Resident #62 Review of Resident #62's medical records found a physician order [REDACTED]. Review of Resident #62's Medication Administration Record [REDACTED] --11/26/17- blood pressure was 118/68. --11/27/17- blood pressure was 118/78. --12/05/17- blood pressure was 118/70. --12/11/17- blood pressure was 118/74. --12/13/17- blood pressure was 118/68. Interview with the Director of Nursing (DON) on 03/13/18 at 11:30 AM found after review of the MARs for (MONTH) and (MONTH) (YEAR). Resident was administered [MEDICATION NAME] when the medication should have been held as directed by the physician prescribed parameters.",2020-09-01
267,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,758,D,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure [MEDICAL CONDITION] medications prescribed on an as needed basis or PRN were limited to a 14 day order, nor did the facility address non-pharmacological interventions prior to the administration of as needed, PRN [MEDICAL CONDITION] medications for one (1) of five (5) residents reviewed for unnecessary medications. This failed practice had the potential to affect more than a limited number of residents. Resident identifier: #61. Facility census: 56. Findings include: a) Resident #61 Record review for Resident #61 found physician order [REDACTED].>--[MEDICATION NAME], give 0.25 mg (milligrams) by mouth every 12 hours as needed for anxiety. Order date 11/02/17 and start date 11/03/17. Review of the MAR indicated [REDACTED] --11/03/17 at 8:13 a.m. --11/05/17 at 10:30 p.m. --11/06/17 at 7:30 p.m. --11/07/17 at 7:49 p.m. --11/08/17 at 8:15 p.m. --11/12/17 at 7:59 p.m. Interview with the Director of Nursing (DON) on 03/15/18 at 11:45 AM confirmed non-pharmacological interventions were not implemented prior to the administration of PRN [MEDICAL CONDITION] medications. Facility failed to attempt non pharmalogical interventions prior to the administration of an anti anxiety medication. ([MEDICATION NAME]) Resident #61",2020-09-01
268,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,803,E,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review and staff interview, the facility failed to make a reasonable effort to assure menus were prepared to meet resident's choices for one (1) of four (4) residents reviewed for the care area of nutrition. Resident #40 received mashed potatoes every day for 49 days in a row. In addition, the facility failed to consider a menu/diet appropriate for a resident after having Laparoscopic gastric band surgery. Resident identifier: #40. Facility census: 56. Findings included: a) Resident #40 During an interview with the resident on 03/12/18 at 10:12 AM., she said, I get mashed potatoes for every meal, I don't know why they can't fortify something else-like some macaroni and cheese for a change. The resident said she was losing weight because she can not eat and the food is not good. Record review found the resident was admitted to the facility on [DATE]. The resident's weight was recorded as 271.3 pounds on 10/06/17. The last weight recorded was 219 pounds on 03/12/18. A 19.28% weight loss since admission. Review of the resident's current care plan, dated 01/03/18, found the following focus/problem: --Risk of altered nutrition/hydration status related to inadequate intake of food and fluids. A goal associated with the problem was: --Resident will remain free of sign/symptoms of dehydration such as sunken eyes, decreased urine output, dry mucous membranes, daily through next review. Interventions included: --Dietary to provide fortified foods one item per tray, initiated on 01/24/18, --Honor food preferences, --Dietary to provide 8 ounces of whole milk with meals, yogurt at 2pm and 1/2 sandwich hs (at night time) Two comprehensive nutritional assessments were completed by the registered dietician (RD) since the resident's admission. On on 10/07/17 and 01/29/18. On 10/07/17, the nutrition summary noted: --New admission. [AGE] year old female .BMI (body mass index) indicates obesity; no interventions warranted due to diagnosis. Will allow resident time to adjust to facility, encourage po (by mouth) intake, and monitor weights per policy .Weight fluctuations may occur due to diuretic . Two weight loss meetings were held, one on 12/01/17 and one on 01/12/18. --12/01/17, Weight meeting held with IDT (interdisciplinary team) members. Weight loss trend continues. PO intake 51-75% of most meals. RD recommendations reviewed 11/30/17 and new order received for house shake BID. Currently receiving whole milk with meals, yogurt daily and 1/2 sandwich at QHS. Resident has a [DIAGNOSES REDACTED]. --01/12/18, Weight meeting held with IDT members. Resident has [DIAGNOSES REDACTED].Several interventions in place including whole milk with meals, yogurt daily at 2 pm per request. HS snack of choice, handmade chocolate milkshakes BID (twice a day), one fortified food item per tray . Review of the hospital discharge summary, dated 10/05/17 found the resident has a surgical history of, Laparoscopic gastric banding surgery. (Laparoscopic gastric banding is surgery to help with weight loss. The surgeon places a band around the upper part of your stomach to create a small pouch to hold food. The band limits the amount of food you can eat by making you feel full after eating small amounts of food.) Normally a person with this surgery would need to eat several small meals daily, instead of three (3) large meals per day. The facility physician also noted the resident had Laparoscopic gastric banding surgery on the, New Patient History and Physical. Observation of the resident's noon meal on 03/12/17 found she had chicken and dumplings and mashed potatoes. Observation of the noon meal again on 03/13/17 found the resident had roast beef and mashed potatoes. At 12:14 PM on 03/13/18, the dietary manager verified the resident does have mashed potatoes for every meal-that is the food we fortify. He confirmed the resident only receives fortified oatmeal for breakfast and fortified mashed potatoes with every lunch and supper. He was not aware the resident had said she was tired of mashed potatoes and could no longer eat them. He said he could fortify some macaroni and cheese as requested by the resident. The DM said he is also unaware the resident had lap band surgery and did not know what kind of a diet the resident should receive after having the surgery. He confirmed the facility had never considered the lap band surgery as contributing to the resident's weight loss. At 8:20 AM on 03/14/18, the resident said she was unable to eat large meals at one setting because of her surgery. She said, If I had the right foods, I could eat more. She said she just requested a hot bowl of chicken noodle soup for lunch. That's all I want and it can even be from a can, just a bowl of hot chicken noodle soup. At 8:57 AM on 03/14/18, the resident's weight loss was discussed with the administrator. She was asked if anyone had every considered the resident's Laparoscopic gastric banding as contributing to her weight loss? The administrator was also notified the resident had been receiving mashed potatoes for every lunch and supper since 01/24/18 because the DM said this was the only food item his staff fortified. (The resident has received mashed potatoes for 49 days in a row for 98 meals.) A third observation of the resident's noon meal at 12:20 PM on 03/14/18, with nursing assistant #91 found the resident received mashed potatoes again. (She did have her chicken noodle soup). At 1:16 PM on 03/14/18, the dietary manager was asked why the resident had mashed potatoes again. He stated, my staff only know how to fortify mashed potatoes, I have to train them to fortify other food items, like the macaroni and cheese-I don't want them to do it the wrong way. Review of the facility's document entitled, Increasing the calorie content of a meal pattern, was reviewed with the DM. Lunch and dinner meals can be [MEDICATION NAME]/fortified with: --Extra margarine to vegetables and starches, serve cheese, cheese sauce, margarine, sour cream on meats, vegetables, or starches; --Offer fortified soup, fortified mashed potatoes or fortified pudding with meals; offer [MEDICATION NAME] milk as a beverage with meals. The DM said those were good ideas for fortifying foods and he would train his staff. At the close of the survey on 03/15/18 at 6:00 PM the facility provided no further information on Resident #40. No information was provided the facility staff addressing the resident's weight loss was aware of the Laparoscopic gastric banding surgery or considered this surgery as contributing to weight loss and attempted to provide a diet that could be tolerated by the resident.",2020-09-01
269,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,804,E,0,1,YXUB11,"Facility failed to provide palatable, attractive and appetizing and proper temperature of food with complaints from 12 anonymous residents. This failed practice had the potential to affect more than a limited number of residents. Facility census: 56. Finding included: a) Anonymous resident statements, from resident council and resident interviews Statements from random residents during resident interviews and resident council meeting. --The bread is always dry like it's been frozen. --Food is cold and mashed potatoes everyday sometimes twice a day --Too many potatoes --The food is either over cooked or under cooked, potatoes every day, the bread is always dried out. --Sometimes I don't even know what the food is. --Today the chicken and dumplings were cold. --They run out of things a lot, the orange juice don't even taste like juice, the vegetables are either over cooked or under cooked. We have told them in resident council, several of us we don't like that old black gravy on everything. --We have a lot of chicken with fancy names, but it ain't good. Sundays pork chop was so tough you can't cut it. --I eat in my room and the food is cold even though it is in a warmer. --I couldn't eat my lunch dried up lima beans and old chicken again. We all agree that we don't like that old brown goo stuff on our food. My meat needs to be cooked good and done. The chicken and dumplings only had 1 piece of meat in it the size of my finger the rest was dough. b) Temperature check on test tray, On 03/13/18 at 11:28 AM, trays arrived on the floor for the Short hall. Many staff members arrive to dispatch trays. They were asked to get a temperature on the last tray to be served on this food cart. Food Service Manager #20 arrived on the floor with thermometer on 03/13/18 at 11:39 AM, to check temperatures of a test tray. Roast beef 108 degrees Fahrenheit. Food Service Manager #20 agreed the temperature of the roast beef was not high enough to meet safe and palatable standards. c) Interviews with Food Service Manager (FSM) and Administrator: On 03/13/18 at 12:00 PM, the Administrator was informed about the food and temperature complaints, and the temperature of the test tray. She said they are working on the food problem and they have food committee. During an interview with FSM#20 on 03/14/18 at 01:35 PM, he was informed the residents had complained about the bread tasting like it was frozen he said, yes it is. Also the lack of variety. He confirmed there was a food committee. During record review the food committee minutes revealed discussion about table clothes and center pieces more then about food. He said they talked about the meal of the month at the beginning of the Resident Council Meeting. On 03/14/18 at 01:50 PM, the FSM #20 confirmed the food committee was more about fine dinning than the food is served. While he was still in the room the administrator was asked what she thought the food committee was about. She said to discuss the likes and dislikes of the kind of food that the residents prefer. She was surprised to know that it was geared more towards the fine dining experience than the food.",2020-09-01
270,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,842,D,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, facility failed to ensure each resident's medical records was complete and accurate. Resident #62 had an inaccurate lab value, International normalized ratio (INR) documented on the resident's anticoagulant ([MEDICATION NAME]) flow record. For Resident #29, the resident's weekly wound/pressure ulcer flow sheets were blank and/or inaccurate. Resident identifiers: #62 and #29. Facility census: 56. Findings included: a) Resident #62 Review of Resident #62's medical records found a [MEDICATION NAME] (anticoagulant) Flow sheet in which read: INR 15.1, normal range is 2.0 to 3.0. Interview with the Director of Nursing (DON) on 0n 03/13/18 at 11:30 AM, confirmed the lab was documented in error. This error was confirmed by Resident #62's physician at 3:47 PM on 03/13/18. b) Resident #29 Resident #29 had pressure ulcers on the right upper/inner posterior thigh and the left outer ankle. Resident #29's right thigh pressure ulcer had been present since (YEAR). Despite the presence of pressure ulcers, Resident #29's Weekly Licensed Nurse Skin Evaluations indicated No for the question Any existing ulcers (previously identified)? for the following dates: --03/02/18 --02/16/18 --01/26/18 --01/19/18 A Weekly Wound Evaluation for Resident #29 on 01/05/18 indicated a left ankle wound was identified on 01/05/18. Weekly Wound Evaluations on 01/12/18, 01/19/18, and 01/26/18 also indicated Resident #29's left ankle wound was identified on 01/05/18. However, Weekly Wound Evaluations on 01/29/18, 02/05/18, and 02/12/18 indicated Resident #29's left ankle wound was identified on 01/05/16. A Weekly Wound Evaluation on 02/14/18 indicated Resident #29's left ankle wound was identified on 01/05/18. Weekly Wound Evaluations on 02/23/18 and 03/09/18 indicated Resident #29's left ankle wound was identified on 01/05/16. Additionally, during review of Resident #29's medical records, Weekly Wound Evaluations for Resident # 29's left ankle wound and right thigh wounds could not be located for the time period between 02/23/18 and 03/09/18. During an interview on 03/14/18 at 12:06 PM, the Director of Nursing (DoN) was informed about the following issues: --Resident #29's Weekly Licensed Nurse Skin Evaluations which indicated No for the question Any existing ulcers (previously identified)? even though the resident did have pre-existing skin ulcers. The DON had no additional information regarding this matter. --The discrepancies on the Weekly Wound Evaluations which indicated Resident #29's left ankle wound was identified on 01/05/18 and 01/05/16. The DoN stated the 01/05/16 dates had been entered in error. --The absence of Weekly Wound Evaluations for Resident's left ankle and right thigh wounds for the week between 02/23/18 and 03/09/18. On 03/14/18 at 1:21 PM, the DON confirmed no Weekly Wound Evaluations had been performed between 02/23/18 and 03/09/18.",2020-09-01
272,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2020-01-15,583,E,0,1,URBH11,"Based on observation and staff interview, the facility failed to ensure resident's personal and health information was kept confidential. Information regarding resident's names, medications, physicians, and how many and what size bowel movements, were visible to the public on the medication cart on the C wing hallway. This had the potential to affect more than a limited number of residents. Resident Identifiers #39, #10, #15, #23, #34, #44, #151, #45, #25, #18, #13, #17, #5, #50, #22, #48, and #1. Facility census 51. Findings included: a) C wing hallway medication cart A random observation on 01/14/20 at 7:51 AM, revealed a bowel management report was lying face up on top of the medication cart in the hallway on the C wing. The information was visible to anyone walking down the hallway. No nursing staff were present to obscure anyone from reading the information on the report. The bowel management report contained the following confidential information: Resident #39 Resident's name, medical record number, room number, physician's name, how many bowel movements the resident had and the size of the resident's bowel movement. Comments on the report indicated the resident received a laxative, which is a medication that loosen stools and increase bowel movements. Resident #10 Resident's name, medical record number, room number, physician's name, how many bowel movements the resident had and the size of the resident's bowel movement. Resident #15 Resident's name, medical record number, room number, physician's name and the size of the resident's bowel movements. Comments on the report indicated the Resident received PJ (Prune Juice). Prune juice can alleviate constipation. Resident #23 Resident's name, medical record number, room number, physician's name, how many bowel movements the resident had and the size of the resident's bowel movement. Resident #34 Resident's name, medical record number, their room number, physician's name, how many bowel movements the resident had and the size of the resident's bowel movements. Comments on the report indicated the the Resident received lax (laxative). Resident #44 Resident's name, medical record number, room number, physician's name, the size of the resident's bowel movement. Comments on the report indicated the Resident received a R/S (rectal suppository.) Rectal suppositories are solid forms of medication, inserted into the rectum to treat constipation. Resident #151 Resident's name, medical record number, room number, physician's name, how many bowel movements the resident had and the size of the resident's bowel movements. Resident #45 Resident's name, medical record number, room number, physician's name, and the size of the resident's bowel movements. Comments on the report indicated the Resident received, PJ (prune juice.) Resident #25 Resident's name, medical record number, room number, physician's name, and the size of the resident's bowel movement. Comments on the report indicated a laxative was given. Resident #18 Resident's name, medical record number, room number, physician's name, and the size of the resident's bowel movement. Comments on the report indicated PJ (prune juice) was given. Resident #13 Resident's name, medical record number, room number, physician's name, and the size of the resident's bowel movements. Resident #17 Resident's name, medical record number, room number, physician's name and how many bowel movements the resident had and the size of the resident's bowel movements. Resident #5 Resident's name, medical record number, room number, physician's name, the size of the resident's bowel movements. Comments included: PJ which indicates (prune juice) was given. Resident #50 Resident's name, medical record number, room number, physician's name, and the size of the resident's bowel movements. Resident #22 Resident's name, medical record number, room number, physician's name, and the size of the resident's bowel movements. Resident #48 Resident's name, medical record number, room number, physician's name, and the size of the bowel movements. Comments included: PJ which indicates (prune juice) was given. Resident #1 Resident's name, medical record number,room number, physician's name and how many bowel movements the resident had and the size of the bowel movements. At 7:40 AM on 01/14/20, Licensed Practical Nurse (LPN) #178, acknowledged the bowel management report contained confidential resident information. In addition, LPN #178 confirmed the information was visible to anyone walking down the C wing hallway.",2020-09-01
273,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2020-01-15,584,D,0,1,URBH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide a safe, sanitary, and homelike environment. This was a random opportunity for discovery. Resident identifier: #11, #38, and #41. Facility census: 51. Findings include: a) room [ROOM NUMBER] / 104 bathroom During the initial tour on 01/13/20 02:42 PM, a commode riser in the bathroom, shared by resident's in rooms [ROOM NUMBERS], was observed to be rusted as well as missing paint. On [DATE] at 2:47 PM, the commode riser was in the bathroom, placed over the toilet. The bathroom is shared by residents in both room [ROOM NUMBER] and room [ROOM NUMBER]. The commode riser appeared to have a rust-colored substance on the front brace, running the length of the brace bar. Also, the back two (2) legs had a rust-colored substance beginning about 1/4 down the front as well as sides of the commode riser. The adjustable holes, used for adjusting the height of the commode, had a rust-colored substance on them as well as rust-colored debris inside the adjustment holes. The arms of the commode riser had rust on the arm braces, extending to the back braces of the commode. In addition, the commode riser had nine (9) separate quarter-sized areas of a brown, dried substance, beginning one inch below the commode seat and extending in a scattered pattern. On [DATE] at 2:51 PM, Employee #178, Licensed Practical Nurse (LPN), observed the commode riser and confirmed the commode riser was rusted and had dried fecal matter present. On [DATE] at 2:52 PM, Employee #200, Registered Nurse (RN), entered the resident bathroom and stated the bedside commode was rusted and would be removed immediately and replaced. RN #200 put on medical exam gloves before removing the bedside commode from the resident's room. At 5:00 PM on [DATE], Director of Nursing stated the bedside commode had been replaced.",2020-09-01
274,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2020-01-15,600,G,0,1,URBH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident was free from neglect. This failed practice caused actual physical harm to Resident #46. This resident sustained [REDACTED]. This practice affected one (1) of three (3) residents reviewed for falls. This failed practice caused actual harm to Resident #46 when she was transferred without the assistance of two staff members (in violation of her care plan) and sustained a fall that resulted in a fractured femur. Resident identifier: #46. Facility census 51. Findings included: a) Resident #46 Review of the Admission, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 0[DATE], revealed the functional status in Section G, concerning transfers, assessed Resident #46 as--total dependence --with two plus person physical assistance when moving from a seated to standing position. The Resident had a Brief Interview for Mental Status (BI[CONDITION]) score of 15, which means the Resident had no cognitive impairment at the time of assessment. Review of the care plan initiated on 06/22/19, revealed the following Problem: Resident is at risk for falls due to impaired mobility, [MEDICAL CONDITION] ([CONDITION]) effects and history of falls. Approach: Transfer with maximum assistance of two (2) staff. Guard extremities with transfers and positioning. Review of the Resident's Kardex Report, revealed Resident #46 was marked as two (2) assist with transfers with an effective date of 06/22/19. A Kardex is a medical information system used by nurses and nursing assistants to communicate important information regarding a resident's care. A progress note, dated 07/22/19 at 9:40 AM, revealed Licensed Practical Nurse (LPN) #36 was called to Resident's room. Resident #46 and Nursing Assistant (NA) #202 were on the floor, Resident complained of right knee pain and area was malformed. Physician notified and order received for x-ray. The x-ray report completed on 07/22/19 at 12:27 PM, for Resident #46 found: Significant fracture deformity with comminution of the distal femur. Acute fracture of proximal fibula and tibia. The Incident and Accident report was completed on 07/22/19. The report noted the fall was witnessed. NA #202 lost her balance while transferring the resident. The Resident and NA #202 fell to the floor, Resident #46 had complaint of pain in right knee and the x-ray showed a fracture. A review of the Five - Day Follow-Up report to the proper State authorities on 07/31/19, revealed findings were substantiated. Resident #46 sustained a distal femur fracture requiring surgical interventions, when lifted improperly by NA #202 when completing the transfer. An interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on [DATE] at 11:00 AM, verified NA #202 had transferred Resident #46 improperly without the assistance of another staff member, which resulted in a serious injury for the Resident. This failed practice caused actual harm to Resident #46 when she was transferred without the assistance of two staff members (in violation of her care plan) and sustained a fall that resulted in a fractured femur.",2020-09-01
275,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2020-01-15,609,D,0,1,URBH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure an allegation of neglect was reported immediately, but not later than two hours after a resident had received a serious injury. Resident #46 sustained an acute [MEDICAL CONDITION], which was caused by neglect of the facility staff. The facility did not report this serious injury to the State Survey Agency or Adult Protective Services. Resident identifier: #46 Facility census: 51. Findings included: a) Resident #46 Review of the Admission, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 0[DATE], revealed the functional status in Section G, concerning transfers, assessed Resident #46 as--total dependence --with two plus person physical assistance when moving from a seated to standing position. The Resident had a Brief Interview for Mental Status (BI[CONDITION]) score of 15, which means the Resident had no cognitive impairment at the time of assessment. Review of the care plan initiated on 06/22/19, revealed the following Problem: Resident is at risk for falls due to impaired mobility, [MEDICAL CONDITION] ([CONDITION]) effects and history of falls. Approach: Transfer with maximum assistance of two (2) staff. Guard extremities with transfers and positioning. Review of the Resident's Kardex Report, revealed Resident #46 was marked as two (2) assist with transfers with an effective date of 06/22/19. A Kardex is a medical information system used by nurses and nursing assistants to communicate important information regarding a resident's care. A progress note, dated 07/22/19 at 9:40 AM, revealed Licensed Practical Nurse (LPN) #36 was called to Resident's room. Resident #46 and Nursing Assistant (NA) #202 were on the floor, Resident complained of right knee pain and area was malformed. Physician notified and order received for x-ray. The x-ray report completed on 07/22/19 at 12:27 PM, for Resident #46 found: Significant fracture deformity with comminution of the distal femur. Acute fracture of proximal fibula and tibia. The Incident and Accident report was completed on 07/22/19. The report noted the fall was witnessed. NA #202 lost her balance while transferring the resident. The Resident and NA #202 fell to the floor, Resident #46 had complaint of pain in right knee and the x-ray showed a fracture. Review of the Five - Day Follow-Up report to the proper State authorities on 07/31/19, revealed findings were substantiated. Resident #46 sustained a distal femur fracture requiring surgical interventions, when lifted improperly by NA #202 when completing the transfer. An interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on [DATE] at 11:00 AM, verified NA #202 had transferred Resident #46 improperly without the assistance of another staff member, which resulted in a serious injury for the Resident. This failed practice caused actual harm to Resident #46 when she was transferred without the assistance of two staff members (in violation of her care plan) and sustained a fall that resulted in a fractured femur. An interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on [DATE] at 1:57 PM, revealed the DON identified the fall sustained by Resident #46 on 07/22/19 as an accident and not neglect, so she didn't report it within two hours. The DON also reported she waited until Resident #46 returned from the hospital on [DATE] to complete the interview with Resident #46. It was only at this time she submitted the allegation of neglect to all the appropriate State agencies. The NHA also verified there was no allegation of neglect reported within two hours to Adult Protective Services or the State Survey Agency.",2020-09-01
276,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2020-01-15,656,E,0,1,URBH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, the facility failed to implement the individual plans of care for three (3) of eighteen (18) sampled residents. The facility failed to implement a care plan for Resident #1 with regard to diet orders. The facility failed to implement a care plan for Residents # 15 and #42 in the area of falls. Resident identifiers: 1, 15, and 42. Facility census: 51. Findings include: a) Resident #1 Record review found a diet order, dated [DATE], Regular Special Instructions: BITE SIZE MEATS 5 SMALL MEALS/DAY **2 HANDLED CUP AT ALL TIMES. On 01/14/20 at 11:38 AM, Resident #1's tray was delivered to her room. The following items were on Resident #1's tray for the noon meal: full serving of meat, full serving of mashed potatoes, roll, slice of pie, bowl of tomato soup, orange jello in a plastic cup, vanilla pudding in a plastic cup, a bowl of applesauce, and a bowl of sliced beets. Employee #161, a Nursing Assistant (NA) was placing the items and setting up Resident #1's tray. NA #161 was asked if the amount of food on Resident #1's tray was what normally comes for her for the noon meal? NA #161 stated the number of items on Resident #1's tray was the normal amount that is placed on her tray. On 01/14/20 at 11:59 AM, during an interview with Employee #201, Dietary Manager(DM). DM #201 was asked what should be on a tray for a resident who is ordered small meals? DM #201 stated for small meals, the resident should be served half (1/2 ) the serving of meat and potatoes called for by the recipe. The resident should not have pudding or jello on their tray. The pudding and / or jello or a supplement would be served to the resident around 2:00 PM. On 01/14/20 at 12:02 PM, DM #201 accompanied the surveyor to view Resident #1's lunch tray. DM #201 stated, Resident #1's family had voiced that they wanted her to have extra pudding and jello on her tray. DM #201 stated there was no order of clarification to the existing diet order of small meals, 5 times a day for Resident #1. DM #201 observed Resident #1's lunch tray and noted the amount of food on the resident's tray was not consistent with the diet order. Review of Resident #1's care plan found a focus problem: (Name of Resident) states that she experienced significant weight loss prior to ECF (extended care facility) admission. Significant weight loss noted since admission with potential for further alteration in nutrition and hydration related to diuretic use, [DIAGNOSES REDACTED]. The goal associated with this problem: (Name of Resident) will consume adequate meals and fluids daily and have no significant weight loss of 5% in 30 days or 10% in 1[AGE] days. Interventions included: -- Encourage intake of food & fluids. Offer food & fluids of choice within diet orders. Offer substitute if doesn't eat meal. Offer snacks & fluids between meals. -- Provide favorite foods and fluids within diet orders. -- 5 (five) small meals per day - all. Further review of Resident #1's medical record revealed the following note: -- 0[DATE]20 2:27 PM, Nursing Progress Note: IDT staff meeting regarding residents weight loss. Resident current weight is 1[AGE].70 lbs. January weight variance report shows that the resident has loosed 20lbs or 11.2% in 182 days, loss of 12 lbs or 7.1% in the last 91 days, loss of 22 lbs or 12.2% in 32 days. Resident has been very sick , in and out of acute care hospital stay. Resident has currently been taking [MEDICATION NAME] [AGE]mg po (by mouth) daily to remove fluid. Resident consumes 1-25% of a regular diet ( 5 small meals daily). Resident consumes a supplements of glucerna. At this time RD recommends that residents glucerna to be D/C (discontinue) and to start Ensure [MEDICATION NAME] 4 oz, po bid (twice a day) with med pass. Resident is currently working with pt (physical therapy) and ot (occupational therapy) for strengthening as well as transferring and encouraging po intake. Resident has family visitors frequently and family encourages resident to eat, as well as bring in home cooked foods. Resident has little to no energy and staff is assisting with all meals. Physician aware of weight loss and new order to d/c glucerna and start Ensure [MEDICATION NAME] 4 oz po bid with med pass. Daughter aware of weight loss and this nurse asked if there was anything that we could try to help with eating. Daughter states that she loves soft desserts and she loves soup and broth , as well as Italian ice, jello with fruit in it as well as ice cream, and oatmeal for breakfast. Dietary clerk called and made aware of the request to be sent on the tray. Nursing staff to encourage po intake and also assess residents weight weekly and monthly. On 01/14/20 at 3:27 PM the findings were discussed with the Administrator. During an interview with the Director of Nursing (DON), on 3:35 PM on 01/14/20, the DON stated she had spoken with the family and had entered in a note into the system. The DON stated Resident #1's diet order had not been modified. The DON stated the progress note on 0[DATE] was to inform the dietary department of Resident #1's preferences for her meals. No further information was provided by the end of the survey on [DATE] at 5:00 PM. b) Resident #15 During the initial tour on 01/13/20 at 1:01 PM, the fall mat on left-hand side of Resident #15's bed was folded in half and lying against heater. On 01/13/20 at 1:03 PM, Employee #149 , Nursing Assistant (NA), was asked to enter Resident #15's room. NA #149 stated that fall mat would not lay down on the floor between the bed and the heater. NA #149 stated that she can never get the fall mat to lie flat, since there is no enough space between the bed and the heater for the fall mat. A review of Resident #15's medical record revealed the following order dated 07/02/18: -- Fall mat to bilateral bed sides d/t (due to) high fall risk - every shift: day shift, evening shift, night shift. Review of Resident #15's care plan found a focus problem: (Name of Resident) is at risk for injury related to falls, generalized weakness, cognitive deficit, poor safety awareness, impulsivity, forgetfulness / confusion at times, hx (history) frequent falls, turns off alarms and attempts to transfer without assistance. The goal associated with this problem: (Name of Resident) will remain free from major injury related to falls throughout the quarter. Interventions included: -- Fall mats to bilateral sides of bed. On 01/13/20 at 1:20 PM, NA #149 stated that she was able to move the bed over and the fall mat was laying flat. On 01/14/20 at 12:57 PM, the findings were discussed with the Administrator. No further information was provided by the end of the survey on [DATE] at 5:00 PM. c) Resident #42 Review of the Admission, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 0[DATE], revealed the functional status in Section G, concerning transfers, assessed Resident #46 as--total dependence --with two plus person physical assistance when moving from a seated to standing position. The Resident had a Brief Interview for Mental Status (BI[CONDITION]) score of 15, which means the Resident had no cognitive impairment at the time of assessment. Review of the care plan initiated on 06/22/19, revealed the following Problem: Resident is at risk for falls due to impaired mobility, [MEDICAL CONDITION] ([CONDITION]) effects and history of falls. Approach: Transfer with maximum assistance of two (2) staff. Guard extremities with transfers and positioning. Review of the Resident's Kardex Report, revealed Resident #46 was marked as two (2) assist with transfers with an effective date of 06/22/19. A Kardex is a medical information system used by nurses and nursing assistants to communicate important information regarding a resident's care. A progress note, dated 07/22/19 at 9:40 AM, revealed Licensed Practical Nurse (LPN) #36 was called to Resident's room. Resident #46 and Nursing Assistant (NA) #202 were on the floor, Resident complained of right knee pain and area was malformed. Physician notified and order received for x-ray. The x-ray report completed on 07/22/19 at 12:27 PM, for Resident #46 found: Significant fracture deformity with comminution of the distal femur. Acute fracture of proximal fibula and tibia. The Incident and Accident report was completed on 07/22/19. The report noted the fall was witnessed. NA #202 lost her balance while transferring the resident. The Resident and NA #202 fell to the floor, Resident #46 had complaint of pain in right knee and the x-ray showed a fracture. A review of the Five - Day Follow-Up report to the proper State authorities on 07/31/19, revealed findings were substantiated. Resident #46 sustained a distal femur fracture requiring surgical interventions, when lifted improperly by NA #202 when completing the transfer. On [DATE] at 3:10 PM, the Director of Nursing (DON) verified Resident #46 was not transferred properly by NA #202, which resulted in a femur fracture. She also reported the Resident was not transferred by two staff as indicated in her care plan.",2020-09-01
277,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2020-01-15,689,G,0,1,URBH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to ensure the resident's environment remains as free of accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents. Resident #46 sustained serious injury during an improper transfer. The fall mat for Resident #15 was not applied properly at bedside. This was true for two (2) of three (3) residents reviewed for the care area of accidents. This failed practice caused actual harm to Resident #46 when she was transferred without the assistance of two staff members (in violation of her care plan) and sustained a fall that resulted in a fractured femur. Resident identifiers: #46 and #15. Facility census: 51. Findings included: a) Resident #46 Review of the Admission, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 0[DATE], revealed the functional status in Section G, concerning transfers, assessed Resident #46 as--total dependence --with two plus person physical assistance when moving from a seated to standing position. The Resident had a Brief Interview for Mental Status (BI[CONDITION]) score of 15, which means the Resident had no cognitive impairment at the time of assessment. Review of the care plan initiated on 06/22/19, revealed the following Problem: Resident is at risk for falls due to impaired mobility, [MEDICAL CONDITION] ([CONDITION]) effects and history of falls. Approach: Transfer with maximum assistance of two (2) staff. Guard extremities with transfers and positioning. Review of the Resident's Kardex Report, revealed Resident #46 was marked as two (2) assist with transfers with an effective date of 06/22/19. A Kardex is a medical information system used by nurses and nursing assistants to communicate important information regarding a resident's care. A progress note, dated 07/22/19 at 9:40 AM, revealed Licensed Practical Nurse (LPN) #36 was called to Resident's room. Resident #46 and Nursing Assistant (NA) #202 were on the floor, Resident complained of right knee pain and area was malformed. Physician notified and order received for x-ray. The x-ray report completed on 07/22/19 at 12:27 PM, for Resident #46 found: Significant fracture deformity with comminution of the distal femur. Acute fracture of proximal fibula and tibia. The Incident and Accident report was completed on 07/22/19. The report noted the fall was witnessed. NA #202 lost her balance while transferring the resident. The Resident and NA #202 fell to the floor, Resident #46 had complaint of pain in right knee and the x-ray showed a fracture. A review of the Five - Day Follow-Up report to the proper State authorities on 07/31/19, revealed findings were substantiated. Resident #46 sustained a distal femur fracture requiring surgical interventions, when lifted improperly by NA #202 when completing the transfer. An interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on [DATE] at 11:00 AM, verified NA #202 had transferred Resident #46 improperly without the assistance of another staff member, which resulted in a serious injury for the Resident. This failed practice caused actual harm to Resident #46 when she was transferred without the assistance of two staff members (in violation of her care plan) and sustained a fall that resulted in a fractured femur. b) Resident #15 During the initial tour on 01/13/20 at 1:01 PM, the fall mat on left-hand side of Resident #15's bed was rolled in half and laying against the heater. On 01/13/20 at 1:03 PM, Employee #149, Nurse Assistant (NA), was asked to enter Resident #15's room. NA #149 stated that fall mat would not lay down on the floor between the bed and the heater. NA # stated that she can never get the fall mat to lie flat, since there is not enough space between the bed and the heater for the fall mat. A review of Resident #15's medical record revealed the following order dated 07/02/18 -- Fall mat to bilateral bed sides d/t (due to) high fall risk - every shift: day shift, evening shift, night shift. A review of Resident #15's care plan noted the following: Review of Resident #15's care plan found a focus problem: (NAME) is at risk for injury related to falls, generalized weakness, cognitive deficit, poor safety awareness, impulsivity, forgetfulness / confusion at times, hx (history) frequent falls, turns off alarms and attempts to transfer without assistance. The goal associated with this problem: (NAME) will remain free from major injury related to falls throughout the quarter. Interventions included: -- Fall mats to bilateral sides of bed. On 01/13/20 at 1:20 PM, NA #149 stated that she was able to move the bed over and the fall mat was laying flat. On 01/14/20 at 12:57 PM, the findings were discussed with the Administrator. No further information was provided by the end of the survey on [DATE] at 5:00 PM.",2020-09-01
278,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2020-01-15,692,D,0,1,URBH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, the facility failed to provide a diet as ordered by a physician. This was a random opportunity for discovery. Resident identifiers: 1. Facility census: 51. Findings include: a) Resident #1 Record review found a diet order, dated [DATE]: Regular Special Instructions: BITE SIZE MEATS 5 SMALL MEALS/DAY **2 HANDLED CUP AT ALL TIMES. On 01/14/20 at 11:38 AM, Resident #1's tray had been delivered to her room. The following items were on Resident #1's tray for the noon meal: full serving of meat, full serving of mashed potatoes, roll, slice of pie, bowl of tomato soup, orange jello in a plastic cup, vanilla pudding in a plastic cup, a bowl of applesauce, and a bowl of sliced beets. Employee #161, Nurse Aid (NA), was placing the items and setting up Resident #1's tray. NA #161 was asked if the amount of food on Resident #1's tray was what normally comes for her for the lunch and dinner meal? NA #161 stated the number of items on Resident #1's tray was the normal amount that is placed on her tray. On 01/14/20 at 11:59 AM, during an interview with Employee #201, Dietary Manager(DM), DM #201 was asked what should be on a tray for a resident who is ordered small meals? DM #201 stated for small meals, the resident should be served half (1/2 ) the serving of meat and potatoes that the recipe calls for. The resident should not have pudding or jello on their tray. The pudding and / or jello or a supplement would be served to the resident around 2:00 PM. On 01/14/20 at 12:02 PM, DM #201 accompanied the surveyor to view Resident #1's lunch tray. DM #201 stated the Resident's family had voiced that they wanted her to have extra pudding and jello on her tray. DM #201 stated there was no order of clarification to the existing diet order of small meals, 5 times a day for Resident #1. DM #201 observed Resident #1's lunch tray and confirmed the amount of food on the resident's tray was not consistent with the diet order. Review of Resident #1's medical record revealed the following note dated 0[DATE]20 at 2:27 PM, Nursing Progress Note: IDT staff meeting regarding residents weight loss. Resident current weight is 1[AGE].70 lbs. January weight variance report shows that the resident has loosed 20lbs or 11.2% in 182 days, loss of 12 lbs or 7.1% in the last 91 days, loss of 22 lbs or 12.2% in 32 days. Resident has been very sick , in and out of acute care hospital stay. Resident has currently been taking [MEDICATION NAME] [AGE]mg po (by mouth) daily to remove fluid. Resident consumes 1-25% of a regular diet ( 5 small meals daily). Resident consumes a supplements of glucerna. At this time RD recommends that residents glucerna to be D/C(discontinued) and to start Ensure [MEDICATION NAME] 4 oz, po bid (twice a day) with med pass. Resident is currently working with pt (physical therapy) and ot (occupational therapy) for strengthening as well as transferring and encouraging po intake. Resident has family visitors frequently and family encourages resident to eat, as well as bring in home cooked foods. Resident has little to no energy and staff is assisting with all meals. Physician aware of weight loss and new order to d/c glucerna and start Ensure [MEDICATION NAME] 4 oz po bid with med pass. Daughter aware of weight loss and this nurse asked if there was anything that we could try to help with eating. Daughter states that she loves soft desserts and she loves soup and broth , as well as Italian ice, jello with fruit in it as well as ice cream, and oatmeal for breakfast. Dietary clerk called and made aware of the request to be sent on the tray. Nursing staff to encourage po intake and also assess residents weight weekly and monthly. On 01/14/20 at 3:27 PM, the findings were discussed with the Administrator. During an interview with the Director of Nursing (DON), the DON stated she had spoken with the family and had entered in a note into the system. The DON stated Resident #1's diet order had not been modified. The DON stated the progress note on 0[DATE] was to inform the dietary department of Resident #1's preferences for her meals. No further information was provided by the end of the survey on [DATE] at 5:00 PM.",2020-09-01
279,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2020-01-15,842,D,0,1,URBH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain a complete and accurate medical record for Resident #42 for a Pharmacy Regimen Review for [MEDICATION NAME]. This was true for one (1) of five (5) residents reviewed for unnecessary medications. This had the potential to affect more than a limited number of residents. Resident identifier: #42. Facility census 51. Findings included: a) Resident #42 During a medical record review on 01/14/20, it was discovered that a Pharmacy Regimen Review for [MEDICATION NAME] had been presented for a gradual dose reduction on 0[DATE] for Resident #42. The Physician disagreed with the recommendation on 0[DATE]. Further investigation provided no evidence Resident #42 had ever taken [MEDICATION NAME]. In an interview with the Director of Nursing (DON) on 01/14/20 at 2:36 PM, the DON reported Resident #42 had never been on [MEDICATION NAME]. She also called the hospital pharmacy and they had no record indicating Resident #42 ever received [MEDICATION NAME].",2020-09-01
280,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2020-01-15,880,D,0,1,URBH11,"Based on observation, record review, policy review, and staff interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment with regard to respiratory services. This was a random opportunity for discovery. Resident Identifiers: #1 and #34. Facility census 51. Findings include: a) Resident #1 During the initial tour on 01/13/20 at 12:57 PM, Resident 1's Bilevel Positive Airway Pressure (bi-pap) mask was observed lying on the bedside table, not in a bag. There was not a bag for storage present in the Resident's room. On 01/13/20 at 12:59 PM, Employee #54, Nursing Assistant (NA), entered the resident's room. When asked how bi-pap masks were stored, NA #54 stated that they were supposed to be in a bag. NA #54 confirmed a storage bag was not in the Resident's room. NA #54 stated she would inform the nurse and left to get the resident a bag. On 01/14/20 at 3:27 PM, the findings were discussed with the Administrator. No further information was provided prior to the end of the survey on [DATE] at 5:00 PM. b) Resident #34 During the initial tour on 01/13/20 at 11:09 AM, Resident #34's nebulizer mask was observed lying on the table, bedside the resident's recliner. There was not a bag present in the resident's room. Resident #34's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/03/19, noted the resident had a score 15 on the Brief Interview for Mental Status. A BI[CONDITION] score of 15 is the highest score obtainable and indicates that the resident is cognitively intact. Resident #34 stated that she never has a bag and that she would like one, since sometimes the staff drop the mask on the floor. On 01/13/20 at 11:26 AM Employee #149, Nursing Assistant (NA), was asked to enter Resident #34's room. NA #149 was asked how nebulizer hand units and masks were supposed to be stored when not in use. NA #149 stated, they were supposed to be in a bag. NA #149 noted that there was no bag in Resident #34's room and went to inform the nurse. A review of the facility's policy entitled, Aerosol/Nebulizer Treatments revealed the following: .7. After completion of therapy remove mask or retrieve hand unit and place in pre-labeled patient bag. On 01/14/20 at 3:27 PM, the findings were discussed with the Administrator. No further information was provided prior to the end of the survey on [DATE] at 5:00 PM.",2020-09-01
281,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2017-12-07,656,D,0,1,WMI211,"Based on record review and staff interviews, the facility failed to ensure care plans included measurable goals. This was found for one (1) of seventeen (17) residents in the final resident sample. Resident identifier: #30. Facility census: 45. Findings include: a) Resident #30 Review of the resident's care plan found the following goals were not written in measureable terms that would allow for achievement toward the goal to be evaluated: -- Resident will have stable mood & behaviors or be redirected daily. What mood and behaviors were to be addressed and how one would determine whether they decreased was not identified. -- Resident will have ADL (activities of daily living) needs met daily. There was no methodology by which this could be determined. -- Pressure injuries will show healing as evidence by decrease in area through the next evaluation. No location of the injuries or measurements were included to render this goal measurable. -- Optimal breathing pattern will be maintained, O2 (oxygen) via NC (nasal cannula) per orders. What would be considered optimal for this resident was not identified in order enable evaluation of achievement toward the goal. At lunch time on 12/07/17, these findings were brought to the attention of the Director of Nursing, and with the Care Plan Nurse prior to exit on 12/07/17.",2020-09-01
282,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2017-12-07,756,D,0,1,WMI211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the pharmacist failed to identify a medication irregularity for Resident #30. The resident received [MEDICATION NAME] and [MEDICATION NAME] for behavioral disturbances, but had not exhibited any behaviors after experiencing a major decline in both her functional abilities and behaviors. Resident identifier: #30. Facility Census: 45. Findings include: a) Resident #30 Observations at lunch time on 12/04/17 noted this resident in the dining room. The resident moved very little and did not vocalize to any extent. Several staff tried to feed the resident, and even obtained ice cream, but she refused to eat more than a few bites of her meal. Medical record review on 12/04/17 at 1:51 p.m. found Resident #30 was admitted from the community on 09/08/17 and discharged [DATE] to a psychiatric hospital. She reentered the facility from an acute care facility on 10/06/17. Her discharge to the psychiatric facility Minimum Data Set (MDS) assessment for 09/15/17, identified she only needed supervision for her activities of daily living (walking, eating, etc.) except for requiring extensive assistance for toileting. According to her Admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 10/11/17, her [DIAGNOSES REDACTED]. This assessment identified the resident did not walk and required total care for most activities of daily living. No behaviors were assessed during the look back period for this assessment. On 12/06/17 at 11:18 a.m., medical record review found the resident was receiving [MEDICATION NAME] delayed release 250 mg at 8:00 a.m. and 8:00 p.m. for dementia with behavioral disturbances. The resident was also on Donepezil ([MEDICATION NAME]) 10 mg at 20:00 (8:00 p.m.) for unspecified dementia with behavioral disturbances Since her return and major decline, she had not had behaviors, yet remained on [MEDICATION NAME] and [MEDICATION NAME]. From 11/23/17 through 8:00 a.m. on 12/06/17, the electronic Medication Administration Record [REDACTED]. She took her [MEDICATION NAME] daily during this period. On 12/06/17 at 8:40 a.m., an interview with the Social Worker (SW) revealed the resident had behaviors and was sent to a psychiatric facility. While there, the resident became ill and was sent an acute care facility twice. The second time, the resident was admitted to the hospital. The said the resident was seriously ill, and her prognosis was grave. She had the resident returned to the facility as the facility could provide the needed care and the resident would be closer to her family. The SW agreed the resident had not exhibited any behaviors since she had returned to the facility. An interview with Registered Nurse (RN) #40 mid-morning on 12/07/17 verified the resident had not had behaviors since her return to the facility. The RN provided a copy of the resident's (MONTH) (YEAR) behavior flow sheet. No behaviors were noted. The RN provided a copy of the resident's drug regimen review and said there was no additional documentation by the pharmacist regarding the resident's medications. Review of the Chronological Record of Medication Regimen Review for Resident #30, found the pharmacist had reviewed the resident's medications on 10/11/17 and 11/11/17. The pharmacist noted the resident received [MEDICATION NAME] 250 BID (twice a day) dementia and [MEDICATION NAME] for anxiety. The review noted the [MEDICATION NAME] dosage was decreased (although not noted by the pharmacist, the [MEDICATION NAME] was discontinued.) There was no indication the pharmacist identified the use of [MEDICATION NAME] and [MEDICATION NAME], in the absence of behaviors and the resident's overall decline, as an irregularity.",2020-09-01
283,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2017-12-07,758,D,0,1,WMI211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and staff interviews, the facility did not ensure Resident #30's drug regimen was free of unnecessary medications. The resident had a significant decline in her functional and behavioral status, yet she continued to receive [MEDICATION NAME] and [MEDICATION NAME] for dementia with behavioral disturbances. Resident identifier: #30. Facility Census: 45. Findings include: a) Resident #30 Observations at lunch time on 12/04/17 noted this resident in the dining room. The resident moved very little and did not vocalize to any extent. Several staff tried to feed the resident, and even obtained ice cream, but she refused to eat more than a few bites of her meal. Medical record review on 12/04/17 at 1:51 p.m. found Resident #30 was admitted from the community on 09/08/17 and discharged [DATE] to a psychiatric hospital. She reentered the facility from an acute care facility on 10/06/17. Her discharge to the psychiatric facility Minimum Data Set (MDS) assessment for 09/15/17, identified she only needed supervision for her activities of daily living (walking, eating, etc.) except for requiring extensive assistance for toileting. According to her Admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 10/11/17, her [DIAGNOSES REDACTED]. This assessment identified the resident did not walk and required total care for most activities of daily living. No behaviors were assessed during the look back period for this assessment. On 12/06/17 at 11:18 a.m., medical record review found the resident was receiving [MEDICATION NAME] delayed release 250 mg at 8:00 a.m. and 8:00 p.m. for dementia with behavioral disturbances. The resident was also on Donepezil ([MEDICATION NAME]) 10 mg at 20:00 (8:00 p.m.) for unspecified dementia with behavioral disturbances Since her return and major decline, she had not had behaviors, yet remained on [MEDICATION NAME] and [MEDICATION NAME]. From 11/23/17 through 8:00 a.m. on 12/06/17, the electronic Medication Administration Record [REDACTED]. She took her [MEDICATION NAME] daily during this period. On 12/06/17 at 8:40 a.m., an interview with the Social Worker (SW) revealed the resident had behaviors and was sent to a psychiatric facility. While there, the resident became ill and was sent an acute care facility twice. The second time, the resident was admitted to the hospital. The said the resident was seriously ill, and her prognosis was grave. She had the resident returned to the facility as the facility could provide the needed care and the resident would be closer to her family. The SW agreed the resident had not exhibited any behaviors since she had returned to the facility. An interview with Registered Nurse (RN) #40 mid-morning on 12/07/17 verified the resident had not had behaviors since her return to the facility. The RN provided a copy of the resident's (MONTH) (YEAR) behavior flow sheet. No behaviors were noted.",2020-09-01
284,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2018-12-07,550,D,0,1,SPY211,"Based on observation and staff interview, the facility failed to preserve one (1) resident's dignity during a mealtime. Private medical information was discussed with this resident in the presence of other residents dining at the same table. This was found during a random opportunity for observation. Resident identifier: #252. Facility census: 52. Findings included: On 12/03/18 at 12:07 PM, facility Urologist #179 was observed speaking to Resident #252 about confidential medical information while she was eating lunch. Two (2) other residents were dining at the table with Resident #252. Urologist #179 asked Resident #252 about potentially placing a catheter because she can't pee. At 12:12 PM, Urologist #179 was interviewed about the observations. He said that most of the residents in the facility know each other and that a lot of them have catheters. He added, What (Resident #252) said to me didn't make sense anyway. He said the alternative would have been to interrupt Resident #252's lunch and take her to her room to have the conversation in private instead. He said he thought talking to her in front of others while she was eating lunch was a preferable method to communicate the information. He then said, You're right, and added that maybe it should have been a private conversation. On 12/06/18 at 8:39 AM the facility's Director of Nursing (DoN) was informed of the issue. No further information was provided prior to the end of the survey.",2020-09-01
285,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2018-12-07,565,E,0,1,SPY211,"Based on resident interview, policy and procedure review and staff interview, the facility failed to ensure resident grievances/concerns were reconciled in a timely manner for two (2) of 18 residents reviewed during the Resident Council meeting. Resident identifiers: #20. Facility census: 52. Findings included: a) Resolution of Grievances/Concerns A review of the policy and procedure dated 03/01/02 Handling of Complaints/Grievances to the Extended Care Facility (ECF) found All complaints must be reported to the hospital CEO (Chief Executive Officer) or licensed nursing home administrator within 24 hours of the initial report. In the section titled Resident Council Meetings stated that any suggestions or concerns that residents may have are assigned to the appropriate person and shall be followed up in the next meeting. In addition for those residents with suggestions/concerns who wish to remain anonymous or for those residents who are unable to complete a form, the ECF Director of Nursing shall complete the form and submit it along with the meeting ' s minutes to the CEO or COO (Chief Operations Officer) with 24 hours of the meeting. In the Time Guidelines, B. The administrator or designee shall conduct (or direct) an investigation and initiate any corrective action within five (5) working days of receipt. A review of the Resident Council minutes during the survey found that grievances/concerns were reported to the Administrator and Supervisor and resolution was completed by the next monthly meeting or were marked ongoing. The minutes from the 07/09 and 08/06/18 meetings found a concern regarding Restorative nursing being pulled to the nursing units. Not until the 09/10/18 was the issues resolved. No evidence was provided by the facility that the residents received a response to this concern for two (2) months. In an interview with the Nursing Home Administrator (NHA) on 12/04/18 at 2:37 PM, when asked who was the facility Grievance Officer, the NHA stated there was no designated Grievance Officer. The NHA did not provide any evidence as to when grievances/concerns that were voiced in Resident Council were resolved other than by the next Resident Council meeting which was conducted on a monthly basis. b) Resident #20 During an interview with Resident #20 on 12/03/18 at 12:08 PM, Resident #20 stated her personal care items such as shampoo and body wash have come up missing several times from her closet in her room. Resident #20 stated she verbally reported the missing items to a Nurse Aide (NA) name unknown, and the missing items have never been found or replaced by the facility. Review of Resident Council minutes dated 11/05/18 at 2:00 PM revealed that Resident # 20's missing shampoo was reported at that time and left as an ongoing concern without resolution. This concern was documented as reported to the Director of Nursing (DoN) and Administrator (NHA). On 12/03/18 at 2:31 PM during resident council meeting, concern of missing shampoo for Resident #20 was re-addressed and resident council president stated the missing items still have not been returned or placed. The facility's policy reviewed during the survey with effective date of 03/01/02 titled Handling of Complaints/Grievances to the Extended Care Facility stated: Completed forms delivered to staff or verbal complaints received by staff must be sent to the Administrator within twenty-four hours of receipt of complaint. The Administrator or designee shall conduct (or direct) an investigation and initiate any corrective action within five working days of receipt.",2020-09-01
286,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2018-12-07,577,E,0,1,SPY211,"Based on observation, staff interview and policy review, the facility failed to post survey results that were readily available, visible, and accessible to residents and visitors. This had the potential to affect more than a limited number of residents. Facility census: 52. Findings included: a) Survey Results During resident council meeting on 12/03/18 at 2:45 PM resident council president (Resident #101) stated he was unaware survey results were available for residents to review and did not know where the survey results were located. Observation on 12/03/18 at 3:20PM revealed a red sign at the lobby of the entrance that stated: This facility is certified by Medicare/Medicaid and is regularly surveyed by the WV Office of Health Facility Licensure Certification. Written survey results are available in the West Solarium. During an interview on 12/03/18 at 03:22, the Director of Nursing (DoN) #99 stated she does not know where the survey results are posted at and suggested asking the Administrator (NHA) for help finding them. At 03:24 on 12/03/18 during an interview, survey results were located by NHA and were found to be located on a wall identified by the Administer as the West Wing of building. Survey results were kept inside a binder and stored inside a single pocket wall file holder that was mounted adjacent to nursing station. The sign above stated: Federal Regulations require that inspection survey results and plan of corrections are available for public review. Please contact the ECF supervisor to see such documentation.",2020-09-01
287,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2018-12-07,584,D,0,1,SPY211,"Based on observation, and staff interview, the facility failed to ensure that two (2) of 18 sampled residents' rooms and equipment were in good repair. Resident Identifiers: Resident #16 and Resident #1. Facilty census: 51. Findings included: Observations made 12/03/18, at 12:11 PM, revealed both side rails on Resident #16's bed were scraped and rough and areas on the resident's door and walls were scraped. Observations made 12/03/18, at 3:01 PM, revealed scraped walls behind Resident #1's bed and holes in the wall outside the bathroom. An interview with the Maintenance Supervisor, on 12/06/18, at 11:55 AM, confined the areas needing repair in the rooms occupied by Resident #16 and Resident #1. The Maintenance Supervisor stated the areas would be repaired.",2020-09-01
288,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2018-12-07,585,E,0,1,SPY211,"Based on resident interviews, review of policy, staff interview, and observation, the facility failed to provide residents with information on how to file a grievance. This had the potential to affect more that a limited number of residents. Facility census: 52. Findings included: a) Grievances During Residence Council Meeting on 12/03/18 at 2:41 PM, Resident Council President #101 stated that he just learned of the grievance form 2 months ago. The remainder of Residence Council members present stated they did not know how to file a grievance or where to obtain form. Review of the facility's policy with effective date of 03/01/02 titled Handling of Complaints/Grievances to the Extended Care Facility: stated: ECF Suggestion/Concern forms shall be available in solariums and from the Social Worker. All completed ECF Suggestion/Concern Forms and accompanying documentation shall be permanently stored in the Administration file. On 12/04/18 at 2:23 PM observation of A wing Solarium revealed no grievance forms posted or available in the A solarium as stated in the grievance policy. On 12/04/18 at 2:26 PM observation revealed a B/C wing solarium revealed a faded teal colored 8x10 sign hanging above eye level on wall in B/C wing solarium that stated: ECF suggestion/concern Form/Medicare concern form/SMH Customer Complaint Form/Medicare & Medicaid Information. Below the sign was a wall mounted chart holder that contained a thin blue paper binder containing blank forms titled: Summersville Memorial Hospital ECF Suggestion/Concern Form. Positioned directly below the forms was a soiled linen cart blocking access to the forms. During an interview on 12/04/18 at 3:06 PM Administrator (NHA) #72 clarified that the grievance forms were only available in the B/C wing solarium.",2020-09-01
289,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2018-12-07,600,D,0,1,SPY211,"Based on observation, and staff interview the facility failed to ensure the residents were free from abuse, including but not limited to verbal and physical abuse. Resident identifier: #28. Facility census: 52. Findings included: a) Resident # 28 During an observation on 12/03/18 at 11:35 AM, Residents were in dining room trays had just arrived. Physical Therapist Assistant (PTA) #180 was seen by Surveyor take the doll in a blanket from Resident #28 without asking or explaining what she was doing. She then pulled Resident # 28 forward by placing her hand on the back of the resident's head. The resident yelled for her to let go of her head. That is when PTA #180 put her face very close to the face of the resident and said, you are not being very lady like in a loud and harsh tone. She then very roughly placed this resident in a wheelchair. Licensed Practical Nurse (LPN) # 96 was trying to tell the resident what they were doing but was not allowed the time to do so by PTA #180. LPN# 96 realized this resident was not in her wheelchair and PTA # 180 appeared to be frustrated by huffing and throwing up her arms. The correct wheel chair was collected by LPN# 96. Again Resident #28 was not told what they were going to do. PTA #180 got behind the resident placing both hands on her upper back and pushed her forward she directed LPN #96 to place the gait belt behind her. This action of pushing her forward appeared to scare the resident as evidenced by her facial expression and she yelled loudly, stop you are hurting me. PTA #180 did not stop her actions towards Resident #28. It looked as though PTA #180 was pushing her out of her wheelchair. PTA #180 roughly pulled the resident into her wheelchair. When she was removing the belt now in front of the resident she once again put her face inches from the resident's face and repeated, You are not very lady like in a loud tone of voice. On 12/05/18 at 3:20 PM, DoN revealed LPN#96 told her on that day that PTA #180 was rude to the resident right in front of the surveyor and not to ask her to assist PTA#180 again. DoN said that everyone refers to PTA #180 as Sarg (short of Sergeant). The Director of Physical Therapy (DPT) #181 stated that she has had others complain about her being rude and rough with people before. DPT said that there is only a few patients that will allow PTA#180 to work with them. On 12/06/18 at 10:23 AM, during an interview LPN #96, stated that she reported to the DoN that PTA #180 was very rude and rough with Resident # 28 while transferring her to her wheelchair to eat lunch. She said, I didn't like the way she spoke to her by telling her she is not very Lady like and not allowing me enough time to explain to her what we were doing. Review of the employee file for PTA#180 the facility could not provide information that they had had any training dealing or caring for residents with Dementia or Alzheimer.",2020-09-01
290,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2018-12-07,655,D,0,1,SPY211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to fully develop a baseline care plan to address pertinent care needs upon admission. This affected one (1) of 18 residents reviewed for care plans. Resident identifier: #252. Facility census: 52. Findings included: a) Baseline Care Plan Resident #252 was admitted to the facility on [DATE]. On 12/04/18 at 09:20 AM, review of Resident #252's base line care plan (titled Admission Care Plan) revealed only to have resident name written at top, no admitted , no resident identifiers, and no initiation dates for goals or plan of care and no progress dates. On 12/05/18 at 8:40 AM review of the facility's policy titled Care Planning Process with review and revise date of 11/08/18, stated an initial care plan addressing the specific needs of the resident will be developed by the IDT team within 48 hours after admission. During an interview on 12/05/18 at 8:48 Director of Nursing (DoN) #99 agreed care plan was incomplete with no date or time of implementation, no date of admission. DoN #99 also stated that the missing information on the care plan made the care plan unacceptable to use.",2020-09-01
291,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2018-12-07,684,F,0,1,SPY211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy and procedure review, the facility failed to administer medications within acceptable time frames for 7 of 8 sampled residents. Resident Identifiers : Residents #16, # 8, #22, #35, #25, #2, and #18. Findings included: a) Resident #16 1. A review of the Medication Administration Policy, effective date 02/20/18, page 7, verified per standard protocol, medications can be administered one (1) hour before or one (1) hour after scheduled time. 2. An interview with Resident #16, on 12/03/18, at 12:11 PM, revealed the resident suffered from painful arthritis but did not always receive pain medication in a timely fashion because staff are usually late with the medication. 3. Review of the medical record showed Resident #16 to have a physician's orders [REDACTED]. A review of the Medication Administration Record, [REDACTED]. The medication was administered late 23 times in (MONTH) (YEAR) and was late with administration four times during the month of (MONTH) (YEAR). Examples of the late administration were as follows: --[MEDICATION NAME] was given late on 11/14/18 through 11/18/18, 11/20/18, 11/22/18, 11/23/18, 11/27/18, 11/27/18, 11/29/18,11/30/18, 12/01/18, 12/2/18, and 12/03/18. Further review of the MAR indicated [REDACTED]. The medication was given late on 11/13/18, 11/16/18, 11/22/18 and 11/28/18. A review of (MONTH) MARs showed the dose of [MEDICATION NAME] was late 7 of the 10 documented administered doses. Doses were administered late on 09/02/18, 09/05/18, 09/11/18, 09/14/18, 09/17/18, 09/20/18, and 09/23/18. The 20:00 dose was administered as late as 22:16 on 9/23/18 and 22:17 on 09/05/18. 4. An interview with the Director of Nursing on 12/05/18, at 10:19 AM, revealed medications are to be given within the hour of the time ordered. She further stated I understand these pain meds are being given late and the resident is experiencing pain. b) Resident #8 1. A review of the medical record for Resident #8, revealed orders for [MEDICATION NAME] 0.25mg once a morning for Dementia. A review of the Medication Administration Record [REDACTED]. The medication was given exceeding the one (1) hour parameter on the following dates with no explanation on: 10/1/18, 10/02/18, 10/08/18, 10/09/18, 10/18/18, 10/19/18, 10/24, 10/25/18, 10/16/18, and 10/30/18. A review of the MAR for (MONTH) (YEAR), showed [MEDICATION NAME] was given late on 13 of 30 occurences during (MONTH) (YEAR). The medication was given exceeding the one (1) hour parameter for medication administation without explanation on: 11/05/18, 11/08-11/10/18, 11/12/18, 11/17/18, 11/19/18, 11/20- 11/22//18, 11/28-11/30/18. 2. An additional order was noted for [MEDICATION NAME] 0.5 mg at bedtime. A review of the MAR for this medication showed the bedtime dosage was administered late for seven (7) of the ten (10) doses ordered. [MEDICATION NAME] 0.5 mg was given exceeing the one (1) hour parameter for medication adminstration with out explanation on: 11/01/18, 11/02/18, 11/16/18, 11/19/18, 11/24/18, and 11/25/18. On 11/24/18, [MEDICATION NAME] 0.5mg was ordered to be adminstered at 20:00 and was not administered until 22:34. 3. An interview, with the Director of Nursing, on 12/04/18, at 3:45 PM, revealed medications are to be given within the hour of the time ordered and administration of medication are given at times over two (2) hours after the ordered time. She further stated I understand this is wrong and I will fix it. c) Resident #18 Review of the medical record for Resident #18 revealed medications were found to not be given in a timely manner. The times were noted to be longer than alloted timeframes for the medications to be administered. These are the months and days the type of mediction was found to be listed as administered late: The following Medications in (MONTH) 1, (YEAR), through (MONTH) 4, (YEAR) were administered late: --[MEDICATION NAME] administered late on: 09/01/18 through 09/13/18, 09/15/18, 09/17/18, 09/20/18, 09/21/18, 09/26/18, 09/27/18, 09/29/18, 09/30/18, 10/03/18, 10/04/18, 10/10/18, 10/13/18, 10/14/18, 10/16/18, 10/23/18, 10/27/18, 10/28/18, 10/29/18, 10/31/18, 11/01/18, 11/02/18, 11/06/18, 11/07/18, 11/09/18, 11/10/18, 11/12/18, 11/13/18, 11/15/18, 11/19/18, 11/21/18, 11/22/18, 11/25/18, 11/26/18, 11/28/18, 11/29/18, 11/30/18, 12/02/18, and 12/03/18. --Aspirin was administered late on: 09/01/18 through 09/3/18, 09/06/18, 09/13/18, 09/15/18, 09/20/18, 09/21/18, 09/26/18, 09/29/18, 09/30/18, 10/04/18, 10/10/18, 10/13/18, 10/14/18, 10/16/18, 10/23/18, 10/28/18, 10/29/18, 10/31/18, 11/07/18, 11/09/18, 11/10/18, 11/12/18, 11/15/18, 11/19/18, 11/22/18, 11/26/18, --[MEDICATION NAME] was administered late on: 09/01/18 through 09/3/18, 09/06/18, 09/13/18, 09/15/18, 09/20/18, 09/21/18, 09/26/18, 09/29/18, 09/30/18, 10/04/18, 10/10/18, 10/13/18, 10/14/18, 10/16/18, 10/23/18, 10/27/18, 10/28/18, 10/29/18, 10/31/18, 11/07/18, 11/09/18, 11/10/18, 11/12/18, 11/15/18, 11/19/18, 11/22/18, 11/26/18, 12/02/18, and 12/03/18. --Lisinpril was administered late on: 09/01/18 through 09/3/18, 09/06/18, 09/13/18, 09/15/18, 09/20/18, 09/21/18, 09/26/18, 09/29/18, 09/30/18, 10/04/18, 10/10/18, 10/13/18, 10/14/18, 10/16/18, 10/23/18, 10/28/18, 10/29/18, 10/31/18, 11/07/18, 11/09/18, 11/10/18, 11/12/18, 11/15/18, 11/19/18, 11/22/18, 11/26/18, 12/02/18, and 12/03/18. --[MEDICATION NAME] was administered late on: 09/01/18 through 09/3/18, 09/06/18, 09/13/18, 09/15/18, 09/20/18, 09/21/18, 09/26/18, 09/29/18, and 09/30/18. --Humulog insulin was administered lated on: 09/03/18, 09/04/18, 09/17/18, 09/18/18, 09/20/18, 09/27/18, 09/30/18, 10/03/18, 10/27/18, 11/01/18, 11/02/18, 11/06/18, 11/08/18, 11/09/18, 11/12/18, 11/13/18, 11/15/18, 11/19/18, 11/21/18, 11/25/18, 11/28/18, 11/29/18, 11/30/18, --[MEDICATION NAME] was administered late on: 09/01/18 through 09/03/18, 09/13/18, 09/15/18, 09/20/18, 09/21/18, 09/26/18, 09/30/18, 10/04/18, 10/10/18, 10/13/18, 10/14/18, 10/16/18, 10/23/18, 10/28/18, 10/29/18, 10/31/18, 11/07/18, 11/09/18, 11/10/18, 11/12/18, 11/15/18, 11/19/18, 11/22/18, 11/26/18, 12/02/18, and 12/03/18. --[MEDICATION NAME] was administered late on: 09/01/18, 09/04/18, 09/17/18, 09/27/18, 10/03/18, 11/01/18, 11/02/18, 11/06/18, 11/09/18, 11/12/18, 11/13/18, 11/15/18, 11/19/18, 11/21/18, 11/25/18, 11/28/18, 11/29/18, 11/30/18, --[MEDICATION NAME] was administered late on: 09/01/18 through 09/03/18, 09/06/18, 09/13/18, 09/15/18, 09/17/18, 09/20/18, 09/21/18, 09/26/18, 09/27/18, 09/30/18, 10/03/18, 10/04/18, 10/10/18, 10/13/18, 10/14/18, 10/16/18, 10/23/18, 10/27/18, 10/28/18, 10/29/18, 10/31/18, 11/01/18, 11/02/18, 11/06/18, 11/07/18, 11/09/18, 11/10/18, 11/12/18, 11/13/18, 11/15/18, 11/19/18, 11/21/18, 11/22/18, 11/25/18, 11/26/18, 12/02/18, and 12/03/18. --[MEDICATION NAME] was administered late on: 09/01/18 through 09/03/18, 09/06/18, 09/13/18, 09/15/18, 09/17/18, 09/20/18, 09/21/18, 09/26/18, 09/27/18, 09/30/18, 10/04/18, 10/10/18, 10/13/18, 10/14/18, 10/16/18, 10/23/18, 10/28/18, 10/29/18, 10/31/18, 11/07/18, 11/09/18, 11/10/18, 11/12/18, 11/15/18, 11/19/18, 11/22/18, 11/26/18, 12/02/18, and 12/03/18. --[MEDICATION NAME] was administered late on 09/30/18. --Tylenol was administered late on: 09/01/18 through 09/03/18, 09/06/18, 09/13/18, 09/15/18, 09/17/18, 09/20/18, 09/21/18, 09/26/18, 09/27/18, 09/29/18, 09/30/18, 10/03/18, 10/04/18, 10/10/18, 10/13/18, 10/14/18, 10/16/18, 10/23/18, 10/27/18, 10/28/18, 10/29/18, 10/31/18, 12/02/18, and 12/03/18. --Imrathopliam was administered late on: 10/03/18, 10/04/18, 10/10/18, 10/13/18, 10/14/18, 10/16/18, 10/23/18, 10/27/18, 10/28/18, 10/29/18, 10/31/18, 11/01/18, 11/02/18, 11/06/18, 11/07/18, 11/09/18, 11/10/18, 11/12/18, 11/13/18, 11/15/18, 11/19/18, 11/21/18, 11/22/18, 11/25/18, 11/26/18, 11/28/18, 11/29/18, 11/30/18, --[MEDICATION NAME] was administered late on: 10/04/18, 10/10/18, 10/13/18, 10/14/18, 10/16/18, 10/23/18, 10/28/18, 10/29/18, 10/31/18, 11/07/18, 11/09/18, 11/10/18, 11/12/18, 11/15/18, 11/19/18, 11/22/18, 11/26/18, 12/02/18, and 12/03/18. --[MEDICATION NAME] was administered late on: 10/03/18, 10/27/18, --[MEDICATION NAME] was administered late on: 11/07/18, 11/09/18, 11/10/18, 11/12/18, 11/15/18, 11/19/18, 11/22/18, 11/26/18 --[MEDICATION NAME] was administered late on 12/02/18, and 12/03/18. This issue was discussed with the Director of Nursing on 12/4/18 and she verified there was a problem with the timelines and documentation of medication administration timeliness d) Resident #2 Review of the Medical Administration Record (MAR) for (MONTH) 1, (YEAR) through (MONTH) 5, (YEAR) for Resident #2 revealed the following medications were administrated more than an hour after the scheduled time to be given: --Eliquis was administered late on: 09/11/18, 09/12/18, 09/13/18, 09/14/18, 09/15/18, 09/17/18, 09/18/18, 09/19/18, 09/20/18, 09/23/18, 09/24/18, 09/27/18, 09/28/18, 09/29/18, 10/01/18, 10/04/18, 10/05/18, 10/07/18, 10/09/18, 10/12/18, 10/17/18, 10/18/18, 10/21/18, 10/23/18, 10/26/18, 10/30/18, 11/01/18, 11/05/18, 11/06/18, 11/07/18, 11/09/18, 11/1018, 11/12/18, 11/15/18, 11/17/18, 11/19/18, 11/20/18, 11/22/18, 11/25/18, 11/28/18, 11/29/18, 11/30/18, 12/02/18, 12/03/18, and 12/05/18. --[MEDICATION NAME] was administered late on: 09/01/18, 09/03/18, 09/06/18, 09/12/18, 09/13/18, 09/14/18, 09/15/18, 09/17/18, 09/18/18, 09/20/18, 09/27/18, 09/29/18, 10/01/18, 10/04/18, 10/05/18, 10/09/18, 10/12/18, 10/17/18, 10/18/18, 10/21/18, 10/26/18, 10/30/18, 11/01/18, 11/05/18, 11/06/18, 11/07/18, 11/09/18, 11/10/18, 11/12/18, 11/15/18, 11/16/18, 11/19/18, 11/20/18, 11/22/18, 11/25/18, 12/02/18, 12/03/18, and 12/05/18. --[MEDICATION NAME] was administered late on: 09/01/18, 09/03/18, 09/04/18, 09/06/18, 09/11/18, 09/12/18, 09/13/18, 09/14/18, 09/15/18, 09/17/18, 09/18/18, 09/19/18, 09/20/18, 09/23/18, 09/27/18, 09/28/18 09/29/18, 10/01/18, 10/04/18, 10/05/18, 10/07/18, 10/09/18, 10/12/18, 10/17/18, 10/23/18, 10/26/18, 10/30/18, 11/01/18, 11/05/18, 11/06/18, 11/07/18, 11/09/18, 11/10/18, 11/12/18, 11/15/18, 11/19/18, 11/20/18, 11/22/18, 11/25/18, 12/02/18, 12/03/18, and 12/05/18. --[MEDICATION NAME] was administered late on: 09/01/18, 09/03/18, 09/06/18, 09/12/18, 09/13/18, 09/14/18, 09/15/18, 09/17/18, 09/18/18,09/20/18, 09/24/18, 09/27/18, 09/29/18, 10/01/18, 10/04/18, 10/05/18, 10/09/18, 10/12/18, 10/17/18, 10/23/18, 10/30/18, 11/01/18, 11/05/18, 11/06/18, 11/07/18, 11/09/18, 11/10/18, 11/12/18, 11/15/18, 11/19/18, 11/22/18, 11/25/18, 12/02/18, 12/03/18, and 12/05/18. --[MEDICATION NAME] was administered late on: 09/01/18, 09/03/18, 09/04/18, 09/06/18, 09/11/18, 09/12/18, 09/13/18, 09/14/18, 09/15/18, 09/17/18, 09/18/18, 09/19/18, 09/20/18, 09/27/18, 09/29/18, 10/01/18, 10/04/18, 10/05/18, 10/07/18, 10/09/18, 10/12/18, 10/18/18, 10/21/18, 10/23/18, 10/26/18,10/28/18, and 10/30/18, 11/01/18, 11/05/18, 11/06/18, 11/07/18, 11/09/18, 11/10/18, 11/12/18, 11/15/18, 11/19/18, 11/22/18, 11/25/18, 12/02/18, 12/03/18, and 12/05/18. --Humalog Insulin was administered late on: 10/17/18, 10/26/18, 10/27/18, 10/01/18, 10/04/18, 10/05/18, 10/07/18, 10/09/18, 10/12/18, 10/18/18, 10/21/18, 10/23/18, 10/26/18,10/28/18, 10/30/18, 11/07/18, 11/15/18, 11/19/18, 11/25/18, 12/02/18, 12/03/18, and 12/05/18. --[MEDICATION NAME] was administered late on: 11/25/18, 11/28/18, and 11/30/18. An interview with DoN on 12/06/18 at 11:10 AM verified that late medication administration was not identified on the regular Drug Regimen Review and should have been. Furthermore, the DoN said she thought the medications that were late but the policy provided a 2 hour window before and after the administration time. She verified this was incorrect. She went on to say she is now working on a correction plan and will re-elevate. She also said it was because most of the nurses are new. e) Resident #35 Review of the facility's nursing/pharmacy policy Medication Administration stated, Each dose of mediation administered shall be properly recorded in the resident's medical record. Per standard protocol medications can be administered one (1) hour before or one (1) hour after scheduled time. On 12/04/18 at 3:45 PM Director of Nursing agreed medications were given late and stated: I understand that is wrong and I will fix it. Record review for the past 3 months revealed the following medications were administered late for Resident #35 from (MONTH) 1, (YEAR) through (MONTH) 3, (YEAR): --Bactrim was administered late on 09/01/18. --[MEDICATION NAME] was administered late on 09/25/18, 09/26/18, and 09/30/18. --[MEDICATION NAME] was administered late on: 09/01/18, 09/14/18, 09/16/18, 09/20/18, 09/25/18, 09/30/18, 10/08/18, 10/16/18, 10/20/18, 10/24/18, 10/26/18, 11/06/18, and 11/16/18. --Donepezil was administered late on: 09/01/18, 09/14/18, 09/16/18, 09/20/18, 09/25/18, 09/30/18, 10/08/18, 10/16/18, 10/20/18, 10/24/18, 10/26/18, 11/06/18, and 11/16/18. --[MEDICATION NAME] U-100 soultion was administered late on: 09/11/18, 09/23/18, 09/26/18, 10/01/18, 10/02/18, 10/19/18, 10/21/18, 10/23/18, 10/25/18, 10/26/18, 10/28/18, 10/31/18, 11/02/18, 11/03/18, 11/04/18, 11/05/18, 11/06/18, 11/07/18, 11/10/18, 11/11/18, 11/12/18, 11/15/18, 11/19/18, 11/20/18, 11/21/18, 11/26/18, 12/02/18, and 12/03/18. --Lorazapam was administered late on: 09/01/18, 09/14/18, 09/16/18, 09/20/18, 09/25/18, 09/30/18, 10/08/18, 10/16/18, 10/20/18, 10/24/18, 10/26/18, 11/06/18 and 11/16/18. --[MEDICATION NAME] was administered late on: 09/01/18, 09/11/18, 09/14/18, 09/20/18, 09/23/18, 09/25/18, 09/26/18, 09/30/18, 10/01/18, 10/02/18, 10/08/18, 10/16/18, 10/19/18, 10/20/18, 10/21/18, 10/23/18, 10/24/18, 10/25/18, 10/26/18, 10/28/18, 10/31/18, 11/02/18, 11/03/18, 11/04/18, 11/06/18, 11/07/18, 11/10/18, 11/11/18, 11/12/18, 11/15/18, 11/16/18, 11/19/18, 11/20/18, 11/21/18, 11/26/18, 12/02/18 and 12/03/18. --[MEDICATION NAME] was administered late on: 09/01/18, 09/11/18, 09/14/18, 09/16/18, 09/20/18, 09/23/18, 09/25/18, 09/26/18, 09/30/18, 10/01/18, 10/02/18, 10/08/18, 10/16/18, 10/19/18, 10/20/18, 10/21/18, 10/23/18, 10/24/18, 10/25/18, 10/26/18, 10/28/18, 10/31/18, 11/02/18, 11/03/18, 11/04/18, 11/05/18, 11/06/18, 11/07/18, 11/10/18, 11/11/18, 11/12/18, 11/15/18, 11/16/18, 11/19/18, 11/20/18, 11/21/18, 11/26/18, 12/02/18, and 12/03/18. Review of the facility's nursing/pharmacy policy Medication Administration stated, Each dose of mediation administered shall be properly recorded in the resident's medical record. Per standard protocol medications can be administered one (1) hour before or one (1) hour after scheduled time. On 12/04/18 at 3:45 PM Director of Nursing agreed medications were given late and stated: I understand that is wrong and I will fix it. f) Resident #22 The following medications were administered late according to record review for the past 3 months for Resident #22 from (MONTH) 1, (YEAR) through (MONTH) 3, (YEAR): [MEDICATION NAME] was administered late on: 09/08/18, 09/09/18, 09/22/18, 09/26/18, 10/19/18, 10/21/18, 10/29/18, 11/01/18, 11/02/18, 11/03/18, 11/09/18, 11/11/18, 11/14/18, 11/16/18, 11/17/18, 11/19/18, 11/21/18, 11/24/18, 11/25/18, 11/26/18, 11/27/18, and 12/03/18. [MEDICATION NAME] was administered late on: 11/02/18, 11/09/18, 11/11/18, 11/14/18, 11/16/18, 11/19/18, 11/25/18, 11/26/18, and 12/03/18. [MEDICATION NAME] was administered late on: 10/19/18, 10/29/18, 11/01/18, 11/02/18, 11/09/18, 11/16/18, 11/17/18, 11/19/18, 11/24/18, and 11/27/18. Oxybutyin Chloride was administered late on: 09/08/18, 09/09/18, 09/22/18, 10/21/18, 11/02/18, 11/09/18, 11/11/18, 11/14/18, 11/16/18, 11/19/18, 11/25/18, 11/26/18, and12/03/18. [MEDICATION NAME] was administered late on: 09/08/18, 09/09/18, 09/22/18, 09/26/18, 10/21/18, 11/02/18, 11/09/18, 11/11/18, 11/14/18, 11/16/18, 11/19/18, 11/25/18, and 11/26/18. [MEDICATION NAME] was administered late on: 09/08/18, 09/09/18, 09/22/18, 09/26/18, 10/19/18, 10/21/18, 10/29/18, 11/01/18, 11/02/18, 11/03/18, 11/09/18, 11/11/18, 11/14/18, 11/16/18, 11/17/18, 11/19/18, 11/21/18, 11/24/18, 11/25/18, 11/26/18, 11/27/18, and 12/03/18. Review of the facility's nursing/pharmacy policy Medication Administration stated, Each dose of mediation administered shall be properly recorded in the resident's medical record. Per standard protocol medications can be administered one (1) hour before or one (1) hour after scheduled time. On 12/04/18 at 3:45 PM Director of Nursing agreed medications were given late and stated: I understand that is wrong and I will fix it. g) Resident #25 A review of Resident #25's medication administration records (MARs) during the long-term care survey process revealed numerous instances of late medication administration during the three (3) months preceding the survey. The facility policy titled Medication Administration with an effective date of 02/20/18 was reviewed during the survey process and stated, Each dose of medication administered shall be properly recorded in the resident's medical record. Per standard protocol medications can be administered one (1) hour before or one (1) hour after scheduled time. --[MEDICATION NAME] was administered late on the following dates: 09/01/18, 09/02/18, 09/03/18, 09/04/18, 09/05/18, 09/06/18, 09/09/18, 09/10/18, 09/14/18, 09/15/18, 09/16/18, 09/17/18, 09/18/18, 09/20/18, 09/21/18, 09/22/18, 09/25/18, 09/26/18, 09/27/18, 09/28/18, 09/30/18, 10/03/18, 10/06/18, 10/07/18, 10/08/18, 10/09/18, 10/10/18, 10/11/18, 10/13/18, 10/15/18, 10/16/18, 10/17/18, 10/18/18, and 10/19/18. --Bactrim DS was administered late on the following dates: 09/05/18, 09/06/18, and 09/09/18. --[MEDICATION NAME] -was administered late on the following dates: 10/25/18, 10/26/18, 10/27/18, 10/29/18, 11/01/18, 11/02/18, 11/03/18, 11/27/18, 12/01/18, 12/01/18, and 12/04/18. --[MEDICATION NAME] was administered late on the following dates and times: 09/01/18, 09/02/18, 09/03/18, 09/04/18, 09/05/18, 09/06/18, 09/09/18, 09/14/18, 09/15/18, 09/16/18, 09/17/18, 09/18/18, 09/20/18, 09/21/18, 09/22/18, 09/25/18, 09/26/18, 09/27/18, 09/28/18, 09/30/18, 10/03/18, 10/06/18, 10/07/18, 10/08/18, 10/09/18, 10/10/18, 10/11/18, 10/13/18, 10/15/18, 10/16/18, 10/17/18, 10/18/18, 10/20/18, 10/25/18, 10/26/18, 10/27/18, 11/01/18, 11/02/18, 11/03/18, 11/04/18, 11/05/18, 11/06/18, 11/08/18, 11/09/18, 11/10/18, 11/12/18, 11/14/18, 11/15/18, 11/18/18, 11/20/18, 11/24/18, 11/27/18, 12/01/18, and 12/04/18. Eliquis was administered late on the following dates: 09/01/18, 09/02/18, 09/03/18, 09/04/18, 09/05/18, 09/06/18, 09/09/18, 09/10/18, 09/14/18, 09/15/18, 09/16/18, 09/17/18, 09/18/18, 09/20/18, 09/21/18, 09/22/18, 09/25/18, 09/26/18, 09/27/18, 09/28/18, 09/30/18, 10/03/18, 10/06/18, 10/07/18, 10/08/18, 10/09/18, 10/10/18, 10/11/18, 10/13/18, 10/15/18, 10/16/18, 10/17/18, 10/18/18, 10/20/18, 10/25/18, 10/26/18, 10/27/18, 10/29/18, 11/01/18, 11/02/18, 11/03/18, 11/04/18, 11/05/18, 11/06/18, 11/08/18, 11/09/18, 11/10/18, 11/12/18, 11/14/18, 11/15/18, 11/18/18, 11/20/18, 11/22/18, 11/24/18, 11/27/18, 12/01/18, and 12/04/18. [MEDICATION NAME] was administered late on the following dates: 09/01/18, 09/02/18, 09/03/18, 09/04/18, 09/05/18, 09/06/18, 09/09/18, 09/14/18, 09/15/18, 09/16/18, 09/17/18, 09/18/18, 09/20/18, 09/21/18, 9/22/18, 09/25/18, 09/26/18, 09/27/18, 09/28/18, 09/30/18, 10/03/18, 10/06/18, 10/07/18, 10/08/18, 0/09/18, 10/10/18, 10/11/18, 10/13/18, 10/15/18, 10/16/18, 10/17/18, 10/18/18, 10/20/18, 10/25/18, 10/26/18, 10/27/18, 11/01/18, 11/02/18, 11/03/18, 11/04/18, 11/05/18, 11/06/18, 11/08/18, 11/09/18, 11/10/18, 11/12/18, 11/14/18, 11/15/18, 11/17/18, 11/18/18, 11/20/18, 11/24/18, 11/27/18, 11/28/18, 11/29/18, 12/01/18, and 12/04/18. [MEDICATION NAME] was administered late on the following dates: 09/10/18; 09/14/18; 09/15/18; and 09/16/18. [MEDICATION NAME] was administered late on the following dates: 09/02/18, 09/03/18, 09/04/18, 9/05/18, 09/06/18, 09/09/18, 09/14/18, 09/15/18, 09/16/18, 09/17/18, 09/18/18, 09/20/18, 09/21/18, 09/22/18, 09/25/18, 09/26/18, 09/27/18, 09/28/18, 09/30/18, 10/03/18, 10/06/18, 10/07/18, 10/08/18, 10/09/18, 10/10/18, 10/11/18, 10/13/18, 10/15/18, 10/16/18, 10/17/18, 10/18/18, 10/20/18, 10/25/18, 10/26/18, 10/27/18, 11/01/18, 11/02/18, 11/03/18, 11/04/18, 11/05/18, 11/06/18, 11/08/18, 11/09/18, 11/10/18, 11/12/18, 11/14/18, 11/15/18, 11/18/18, 11/20/18, 11/24/18, 11/27/18, 12/01/18, and 12/04/18. [MEDICATION NAME] XR was administered late on the following dates: 09/01/18, 09/02/18, 09/03/18, 09/04/18, 09/05/18, 09/06/18, 09/09/18, 09/14/18, 09/15/18, 09/16/18, 09/17/18, 09/18/18, 09/20/18, 09/21/18, 09/22/18, 09/25/18, 09/26/18, 09/27/18, 09/28/18, 09/30/18, 10/03/18, 10/06/18, 10/07/18, 10/08/18, 10/09/18, 10/10/18, 10/11/18, 10/13/18, 10/15/18, 10/16/18, 10/17/18, 10/18/18, 10/20/18, 10/25/18, 10/26/18, 10/27/18, 11/01/18, 11/02/18, 11/03/18, 11/04/18, 11/05/18, 11/06/18, 11/08/18, 11/09/18, 11/10/18, 11/12/18, 11/14/18, 11/15/18, 11/18/18, 11/20/18, 11/24/18, 11/27/18, 12/01/18, and 12/04/18. Potassium chloride was administered late on the following dates: 09/01/18, 09/02/18, 09/03/18, 09/04/18, 09/05/18, 09/06/18, 09/09/18, 09/14/18, 09/15/18, 09/16/18, 09/17/18, 09/18/18, 09/20/18, 09/21/18, 09/22/18, 09/25/18, 09/26/18, 09/27/18, 09/28/18, 09/30/18, 10/03/18, 10/06/18, 10/07/18, 10/08/18, 10/09/18, 10/10/18, 10/11/18, 10/13/18, 10/15/18, 10/16/18, 10/17/18, 10/18/18, 10/20/18, 10/25/18, 10/26/18, 11/01/18, 11/02/18, 11/03/18, 11/04/18, 11/05/18, 11/06/18, 11/08/18, 11/09/18, 11/10/18, 11/12/18, 11/14/18, 11/15/18, 11/18/18, 11/20/18, 11/24/18, 11/27/18, 12/01/18, and 12/04/18. [MEDICATION NAME] was administered late on the following dates: 09/01/18, 09/03/18, 09/05/18, 09/10/18, 10/09/18, 10/25/18, 10/29/18, 11/05/18, 11/22/18, and 12/01/18. [MEDICATION NAME] (used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder) in the amount of 1 mg was administered late on the following dates and times: 09/01/18, 09/03/18, 09/05/18, 09/10/18, 10/09/18, 10/25/18, 10/29/18, 11/05/18, 11/22/18, and 12/01/18. [MEDICATION NAME] was administered late on the following dates: 09/01/18, 09/02/18, 09/03/18, 09/04/18, 09/05/18, 09/06/18, 09/09/18, 09/10/18, 09/14/18, 09/15/18, 09/16/18, 09/17/18, 09/18/18, 09/20/18, 09/21/18, 09/22/18, 09/25/18, 09/26/18, 09/27/18, 09/28/18, 09/30/18, 10/03/18, 10/06/18, 10/07/18, 10/08/18, 10/09/18, 10/10/18, 10/11/18, 10/13/18, 10/15/18, 10/16/18, 10/17/18, 10/18/18, 10/20/18, 10/24/18, 10/25/18, 10/26/18, 10/27/18, 10/29/18, 11/01/18, 11/02/18, 11/03/18, 11/04/18, 11/05/18, 11/06/18, 11/08/18, 11/15/18, 11/18/18, 11/20/18, 11/09/18, 11/10/18, 11/12/18, and 11/14/18. On 12/04/18 at 3:07 PM, the facility's Director of Nursing (DoN) acknowledged that Resident #25's medications had been given late numerous times over the three (3) months preceding the survey. She stated that there was a second facility medication administration policy that allowed staff to administer medications up to two (2) hours before or after their ordered administration time instead of only one (1) hour. However, many of the medications were given outside of this extended time window and the DoN acknowledged this. She said the reason so many medications were given late was that the facility had hired some new Licensed Practical Nurses (LPNs) who had just finished school. She said the facility was aware of the problem and was trying to address it by changing medication administration times. She added that when a medication was given late, it was not documented in the medical record. A copy of the second medication administration policy was requested at that time. On 12/04/18 at 3:26 PM, the DoN provided the second policy stating that medication could be administered two (2) hours before or after the ordered time. However, she stated that this was a hospital policy instead of a policy for the Extended Care Facility (ECF) distinct part. The policy, titled Medication: Standard Hours for Drug Distribution, was last reviewed on 08/23/16 and stated, Non-critical times PO (by mouth) medications may be given 2 hours before or 2 hours after their scheduled time. The DoN acknowledged that the hospital policy did not match the standard of practice for medication administration times in nursing homes or the pharmacy policy for medication administration. On 12/06/18 at 8:39 AM, the DoN was informed of this issue. No further information was provided by the facility prior to exit.",2020-09-01
292,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2018-12-07,697,D,0,1,SPY211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and resident interview, the facility failed to provide pain management in accordance with physician's orders for one of 18 sampled residents who experienced pain. Resident identifier: #16. Facility census: 52. Findings included: a) Resident #16 1. A review of the Medication Administration Policy, effective date 02/20/18, page 7, verified per standard protocol, medications can be administered one (1) hour before or one (1) hour after scheduled time. 2. An interview with Resident #16, on 12/03/18, at 12:11 PM, revealed the resident suffered from painful arthritis but did not always receive pain medication in a timely fashion, stating staff are usually late with the medication. 3. Review of the medical record showed Resident #16 to have a physician's orders for a [MEDICATION NAME] every 12 hours, [MEDICATION NAME] 25 mcg/hr once a day every third day. 4. A review of the Medication Administration Record, [REDACTED]. The medication was administered late 23 times in (MONTH) (YEAR) and was late with administration four times during the month of (MONTH) (YEAR). Examples of the late administration were as follows: --[MEDICATION NAME] was given late on 11/14/18 through 11/18/18, 11/20/18, 11/22/18, 11/23/18, 11/27/18, 11/27/18, 11/29/18,11/30/18, 12/01/18, 12/2/18, and 12/03/18. 5. Further review of the MAR indicated [REDACTED]. The medication was given late on 11/13/18, 11/16/18, 11/22/18 and 11/28/18. 6. A review of (MONTH) MARs showed the dose of [MEDICATION NAME] was late 7 of the 10 documented administered doses. Doses were administered late on 09/02/18, 09/05/18, 09/11/18, 09/14/18, 09/17/18, 09/20/18, and 09/23/18. The 20:00 dose was administered as late as 22:16 on 9/23/18 and 22:17 on 09/05/18. 7. An interview with the Director of Nursing, on 12/05/18, at 10:19 AM, revealed medications are to be given within the hour of the time ordered. She further stated I understand these pain meds are being given late and the resident is experiencing pain.",2020-09-01
293,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2018-12-07,804,D,0,1,SPY211,"Based on observation, staff interview, resident interview, and record review, the facility failed to provide food and drink that was safe and at an appetizing temperature. Residents reported being served cold food that was not palatable. This had the potential to affect more than a limited number of residents. Resident identifier: #16. Facility census: 52. Findings included: a) Resident #16 During an interview on 12/03/18 at 2:12 PM Resident #16 stated the food was still being served cold, that she liked her soup hot and it was never warm enough for her eat. Resident council minutes dated 10/01/18 revealed Resident #16 voiced a concern of cold food when delivered with corrective action as trays would be passed in a more timely manner and facility do a test tray. Resident council minutes dated 11/05/18 also revealed that Resident #16 complained the food was not hot when served. b) Test Tray On 12/05/18 at 11:39 AM observation for test tray started when staff started passing trays in B/C wing solarium. At 11:46 AM trays split between carts for meal tray hall pass. At 11:51 AM just prior to being served, notified staff that the last tray left on meal cart will be tested . Test tray temperatures obtained by Dietary Manager (DM) #170 at 11:55 AM consisting of: --Ground spaghetti with meat temperature 125 degrees Fahrenheit (F). --Spinach 1/2 cup temperature of 118 degrees (F). --Ground citrus cup temperature 48 degrees (F) --Chocolate milk temperature 51 degrees (F) --Grape juice temperature 51 degrees (F) --Gelatein (nutritional supplement) temperature 48 degrees (F) --Garden Salad temperature 60 degrees (F) c) Dietary Manager Interview During an interview on 12/05/18 at 2:30 PM Dietary Manger (DM) #170 stated she was aware that some of the residents have complained about cold food, and they have tried staggering out the meal times and tray line processing to allow meal trays to be delivered more timely while hot.",2020-09-01
294,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2018-12-07,812,E,0,1,SPY211,"Based on observation, staff interview, and policy review, the facility failed to ensure that resident food was stored appropriately in unit refrigerators and that a unit microwave was kept clean. This had the potential to affect more than a limited number of residents. Facility census: 52. Findings included: On 12/03/18 at 11:24 AM, a tour of the facility's main kitchen, waste disposal areas, and unit kitchens began with Certified Dietary Manager (CDM) #170. At 11:46 AM, the microwave in the A wing unit kitchen was found to be dirty. Multiple droplets of a pink substance were present on the bottom of the inside of the microwave. CDM #170 acknowledged that the microwave was dirty. At 11:50 AM, a pie with one (1) piece missing was found in the B wing refrigerator. It was marked with a date of 11/28/18. A sticker on the refrigerator stated that resident food should be discarded after three (3) days. CDM #170 confirmed that the pie should have been removed after three (3) days. Also at 11:50 AM, a plastic reusable container with food in it was found in a plastic shopping bag in the B wing refrigerator. The container was not labeled with any dates or identifying information. CDM #170 said she was concerned about this and removed it from the refrigerator, along with the pie. She said she would discard both items. At 2:51 PM, the facility's policy for food brought into the facility for residents was obtained and reviewed. The policy, titled Patient Food from Non-Hospital Sources was most recently reviewed on 05/19/18 by CDM #170. The policy stated, Any food brought in from the outside shall be labeled with patient's name, date and room number, and held in a unit refrigerator specifically designated for patient food, for 24- hours only. A document titled Safe Food Handling Tips was provided with the policy and stated, All cooked or prepared foods stored in pantry or refrigeration will be checked daily by the diet clerk from Nutrition Services, and will be tossed if not properly labeled. On 12/06/18 at 8:39 AM the facility's Director of Nursing (DoN) was informed of the issue. No further information was provided prior to the end of the survey.",2020-09-01
295,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2018-12-07,880,D,0,1,SPY211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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. The nurse failed to use a protective barrier when she placed the two inhalers on the resident's side table and failed to provide isolation precautions by not posting signs alerting the public of an infection control risk for residents in isolation. These were random Resident opportunities for discovery. Identified Residents #14 and #16. Facility census was 52. Findings included: a) Resident #14 On 12/04/18 at 7:45 AM, Licensed Practical Nurse (LPN) #78 failed to place a barrier on Resident's #14 bedside table before laying to inhalers on the table. LPN#78 said she realized what she did as soon as she did it and that is why she wiped the inhalers off with an alcohol pad. On12/04/18 at 12:38 PM, Director of Nursing (DoN) was informed of observation and said that LPN#78 had already told her about it. b.) Resident #16 Observations during the tour, on 12/03/18, at 12:00 PM, , revealed no precautionary measures alerting staff and visitors to obtain more information about care provided to Resident #16 before entering the room. b.) A review of the medical record for Resident #16, showed the resident was being isolated in Contact Isolation for an infection as of 11/25/18, c.) An interview with LPN #137, on 12/03/18, at 01:51, revealed Resident #16 was being isolated for [MEDICAL CONDITION] but verified there was no sign on the door to alert staff and visitors that extra precautions would be required when entering the room. LPN #137, further stated, a sign that stated STOP should have been on the resident's door. d.) An interview with the infection control nurse, on 12/03/18, at 2:10 PM, verified the isolation policy required a sign on the door but stated it must have fallen off. e.) Review of the policy and procedure Isolation Procedure, dated (MONTH) 5, 2007, showed a large sign will be placed on the outside of the resident's door informing all to see the nurse before entering the room.",2020-09-01
296,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2018-12-07,947,E,0,1,SPY211,"Based on inservice record review and staff interviews, the facility failed to ensure Nurse Aides (NA's) received the required twelve (12) hours of annual inservice training. This practice was true for three (3) of employee inservice records reviewed. Employee identifiers: #145, #65, #155. Facility census: 52. Findings include: On 12/05/18 02:36 PM a review of inservice records found three (3) of five (5) inservice records for NA's #145 (hire date 05/02/16), #65 (08/04/08), #155 (hire dated (05/10/17) had no evidence of the required 12 hours of inservices. An interview with Registered Nurse (RN #173), stated that the previous nursing educator had retired and produced a copy of the nursing schedule with a hand written Infection Control, Handwashing and PPE's (personal protected equipment) at the top of the schedule. Red check marks were beside staff names who attended the inservice. RN #173 was unable to confirm the length of time of the inservices. RN #173 stated that she would try to contact the retired inservice educator to obtain the length of the inservices. An additional interview on 12/06/18 at 8:12 AM, RN #155 confirmed there was no evidence of the number of hours of inservice education provide for the facility NA's.",2020-09-01
297,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,167,C,0,1,UN5811,"Based on observations and staff interview, the facility failed to have a notice posted as to the location of the most-recent survey results during a random observation. This has the potential to affect all residents and visitors. Facility census 81. Findings include: a) Observation On 03/05/17 during an initial tour of the facility, the recent State survey results were observed in the main dining room in a box on the wall. A notice as to the location of the survey results was not observed during the survey week (03/05/17- 03/08/17). b) Interview During an interview with the Administrator, on 03/08/17 at 10:30 a.m., the Administratorwas asked where the notice was located to inform a visitor where the survey results would be located. The Administrator said we do not have a notice. She was not aware a posting was required to inform visitors of where to find the facility's survey results.",2020-09-01
298,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,241,D,0,1,UN5811,"Based on observation and staff interview, the facility failed to ensure Resident #7 was provided with a dignified dining experience during the breakfast meal on 03/06/17. This was a random opportunity for discovery. Resident identifier: #7. Facility census: 81. Findings include: a) Resident #7 During an observation at 9:02 a.m. on 03/06/17, Nurse Aide (NA) #65 was observed feeding Resident #7. NA #65 was standing at the residents bedside instead of being seated where she could be at eye level with Resident #7. An interview with NA #65, at 9:06 a.m. on 03/06/17, confirmed she was standing instead of sitting down while feeding Resident #7. She stated she should have been sitting, but there was no chair in the residents room to sit on so she had to stand. She stated, You can look in all these rooms there are no chairs in any of them.",2020-09-01
299,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,246,D,0,1,UN5811,"Based on observation, resident interview, and staff interview, the facility failed to provide reasonable accommodations of individual needs for one (1) of thirty-five (35) residents during a random opportunity for discovery during Stage I and Stage II of the Quality Indicator Survey (QIS). A resident's call light was not within reach. Resident identifier: #78. Facility census: 81. Findings include: a) Resident #78 During Stage 1 of the Quality Indicator Survey (QIS), on 03/05/17 at 2:54 p.m., an observation revealed Resident #78's call light was not within his reach while he was lying in bed. During Stage 2 of the QIS, an observation and interview with Specialist Maintenance 2 (SM2) #19, on 03/08/17 at 8:32 a.m., found Resident #78's call light on the floor, and not within the resident's reach. SM2 #19 verified the placement of the call light was out of reach of the resident, and the resident would not be able to use the call light. During Stage 2 of the QIS, on 03/08/17 at 9:05 a.m., the resident was lying in his bed and he was observed by the assistant director of nursing (ADON) #45. The resident's call light was lying on the floor. Resident #78 was asked by this surveyor whether he used his call light and Resident #78 stated, Yes, I use my call light. The ADON picked the resident's call light off the floor and attached his call light within the resident's reach. The resident was asked by this surveyor to ring his call light. The resident reached down and pushed the button and the light turned red on the wall. The ADON agreed the resident's call light was not in reach and therefore the resident was unable to use his call light for assistance if wanted to.",2020-09-01
300,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,253,E,0,1,UN5811,"Based on observations and staff interview, the facility failed to provide maintenance and housekeeping services necessary to maintain a comfortable and sanitary interior for six (6) of thirty-five (35) resident rooms observed during Stage 1 of the Quality Indicator Survey (QIS). The entrance doors to the resident's rooms had deep gouges, in which the wood was exposed with no finish on the door. The wall in one room was cracked. The floor tile was cracked, and there was a discolored substance on the caulking which was around the sink and the air conditioner. A bathroom had been missing paint on the door facing going into the bathroom, and tape and white mark was on the bathroom doors. A gray raised toilet seat has an area of rust color where a resident's legs would touch. This had the potential to affect more than an isolated number of residents. Resident room identifier: 101,102,103,106,115, and 118. Facility census 81. Findings include: a) Cosmetic imperfection --Room 101 observed, on 03/05/17 at 12:03 p.m., found cracked floor tiles on the side of the air conditioner unit. There was deep gouges in the woood below the door handle on the side of the entry door. The wood was exposed with no finish on the door. --Room 102 observed, on 03/05/17 at 2:52 p.m., found deep gouges in the wood of the door leading into the room on the outside edges, and there was chunks of wood missing off the door. --Room 103 observed, on 03/05/17 at 12:33 p.m., found cracked floor tile under the sink and dark spaces showing between the tiles. The hand sink had a large amount of black markings on the caulking. --Room 105 observed, on 03/05/17 at 12:28 p.m., found a crack in the wall above the air conditioner with a brown color substance on the white caulking. --Room 115 observed, on 03/05/17 at 12:05 p.m., found deep gouges on the entry door to the resident's room and missing paint in the door facing of the bathroom door. --Room 118 observed, on 03/05/17 at 12:41 p.m., found tape marks and white marks on the insdie of the inside of the bathroom door. The caulking around the sink is yellowish/brown in color and cracked. --Room 137 observed, on 03/05/17 at 2:13 p.m., found the front part of the gray raised toilet seat where a resident's legs goes across would touch an area of discolored rust color. b) Interview with the Specialist Maintenance 2 (SM2) In an interview and observation with the SMT2, on 03/08/17 at 8:28 a.m., he observed the above findings and verified the observed cosmetic imperfections all needed to be repaired.",2020-09-01
301,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,272,D,0,1,UN5811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to conduct an accurate comprehensive Minimum Data Set (MDS) assessment for one (1) of three (3) residents reviewed for the care area of accidents. The MDS assessment for Residents #26 was inaccurate in the area of behavior patterns. Resident identifier: #26. Facility census: 81. Findings include: a) Resident #26 A review of Resident #26's medical records, on 03/07/17 at 1:30 p.m., revealed an admission date of [DATE]. The medical records contained an annual MDS with an assessment reference date (ARD) of 01/13/17. This MDS, in item E1000A for Wandering - Impact, indicated Resident #26's wandering placed the resident at significant risk of getting to a potentially dangerous place (e.g. stairs, outside of the facility). Further review of the medical records on 03.07/17 at 2:00 p.m., found no evidence and/or documentation Resident #26 wandered into dangerous areas. Tthere was no evidence found during the look back period for the referenced MDS for the behavior of wandering. During an interview, on 03/07/17 at 3:45 p.m., the Director of Nursing (DON) and the Social Service Director (SSD), both confirmed the MDS with an ARD of 01/13/17 was inaccurate. The MDS was immediately corrected by the SSD.",2020-09-01
302,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,274,D,0,1,UN5811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, minimum data set (MDS) 3.0 resident assessment instrument (RAI) manual, the facility failed to complete a significant change Minimum Data Set (MDS) assessment for one (1) of twenty-one (21) residents Stage 2 sample residents during the Quality Indicator Survey (QIS). Resident #63 experienced a significant change when the resident and/or her responsible party elected to participate in hospice services. Resident identifier: #63. Facility Census: 81. Findings include: Review of Resident #63's medical records found the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nursing notes dated 12/21/16 read, . social worker spoke with resident concerning hospice services and the resident in agreement moved to private room for comfort . Review of physician progress notes [REDACTED]. Patient with a history of craniotomy with a poor prognosis sent back to nursing home with hospice . Hospice consulted Prognosis poor. Hospice services started on 12/27/16 for the [DIAGNOSES REDACTED]. A five (5) day MDS assessment with an assessment reference date (ARD) of 12/26/16 and a discharge tracking death in facility MDS with ARD of 12/30/16 were found in the residents record, no further MDS assessments were found in the record. Review of the MDS 3.0 resident assessment instrument (RAI) manual read, A significant change status MDS is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare Hospice or other structured hospice) and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). A significant change status assessment must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving his/her highest practicable well-being at whatever stage of the disease process the resident is experiencing. During an interview on 03/07/17 at 2:00 p.m., Employee #24, MDS coordinator, stated she missed the significant change. She further explained her corporate office stated it was not necessary to complete the significant change MDS. Director of Nursing and the Nursing Home Administrator notified on 03/07/16 at 3:15 p.m., of the missed significant change MDS for Resident #63. No further information provided.",2020-09-01
303,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,282,D,0,1,UN5811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to implement the care plan for one (1) of one (1) residents reviewed for the care area of Hospice. The facility did not have current notes written by licensed Hospice staff. In addition, the facility was not provided with a schedule indicating when the visits of the Hospice nurse aide (NA) would occur. Resident identifier: #6. Facility census: 81. Finding include: a) Resident #6 Review of the physician's orders [REDACTED]. Review of the care plan found the following problem: --Patient is on Hospice care related to: End of life care. The goal associated with the problem was: --Patient will be comfortable and have needs meet thru next review. Approaches included: --All Hospice staff visits will be documented in resident chart. --Social services to visit twice a month, NA (nurse aide) 2-3 times per week, nurse to visit 1-2 times per week and as needed to assess and manage care, weekly volunteer companion. --NA schedule for Hospice to be posted in resident's room. Observation of the resident's room found the (MONTH) calendar for hospice nurse aide visits was not posted in the resident's room. At 12:04 p.m. on 03/07/17, NA #14 found a calendar for the month of (MONTH) (YEAR), but was unable to locate the March, (YEAR) calendar. NA #14 said the calendar is usually on the resident's bulletin board. NA #14 said she thought the Hospice NA visits the resident on Tuesdays, Wednesdays and Thursdays. At 12:04 p.m. on 03/07/17, notes written by the Hospice staff were located in a binder at the nurses desk by Registered Nurse (RN) #23. The most recent nurses' note in the binder was dated 02/21/17. An interview with the director of nursing (DON), at 12:51 p.m. on 03/07/17, found the Hospice agency is now documenting their notes in the computer and the facility has access to these notes. At 12:56 p.m. on 03/07/17, the administrator reviewed the Hospice notes in the computer and confirmed the last Hospice note was written on 02/21/17. The administrator provided a copy of the NA schedule for (MONTH) (YEAR) and confirmed the March, (YEAR) schedule was not available to the facility. The administrator said she would contact the Hospice agency as the nursing notes were not up to date. The DON said the Hospice nurse had visited the facility since 02/21/17. At 1:00 p.m. on 03/07/17, the DON confirmed the care plan was not implemented as directed.",2020-09-01
304,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,323,E,0,1,UN5811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, record review, and review of multiple Material Safety Data Sheets (MSDS), the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. The supply closet located on the East Short Hallway was not locked and contained multiple chemicals that were hazardous if they came in contact with the residents eyes or skin or swallowed. This had the potential to effect Resident #91, #26, #108, and #79 all of whom were independently mobile and cognitively impaired which put them at risk for opening the closet door and having access to potentially harmful chemicals. Resident #41 and #9 were identified as having loose side rails during Stage 1 of the Quality Indicator Survey. For Resident #79, the facility failed to perform a root cause analysis when she suffered an injury to determine the cause and contributing factors of the injury. These practices effected seven (7) of 37 Stage 2 sampled residents. Resident identifiers: #91, #26, #108, #79, #41, and #9. Facility census: 81. Findings include: a) Supply Closet Observations of the supply closet on the East Short Hall, at 12:23 p.m. on 03/05/17, found the door to the supply closet was unlocked. Stored inside the closet were multiple chemicals which were used by the housekeeping department to clean the facility. Registered Nurse #29 confirmed the door is usually locked and she does not know why it is unlocked. She stated that she would have to get someone else to get the MSDS sheets for the chemicals because she was not sure where they were kept. Later in the afternoon the Housekeeping supervisor provided the MSDS sheets and again confirmed the door was to be kept locked at all times. She stated she was not sure why it was unlocked earlier in the day. A review of the MSDS sheets found the following for each chemical stored in the East Short Hall Supply Closet: --Shineline Floor Prep MSDS sheet contained the following: Section V: Health Hazard Data the following effects of overexposure- conditions to avoid were found: Corrosive: Causes eye damage: Symptoms include pain, redness, tissue destruction with possible corneal damage. Causes skin damage: Symptoms include pain, redness, tissue destruction, and chemical burns. Harmful if swallowed: (MONTH) cause damage or chemical burn to esophagus and mucous membranes with symptoms of pain, nausea, vomiting and diarrhea. (MONTH) be harmful if inhaled: Breathing product mist may cause irritation of the respiratory tract with symptoms of nasal discomfort and discharge with chest pain and coughing. Do not get in eye, on skin or clothing. Avoid Breathing product mist. Do not taste or swallow. Wash Thoroughly after handling. --CBC Plus toilet bowl cleaner MSDS Sheet contained the following: Section 3. Hazards identification: .Emergency overview Danger! causes digestive tract, eye and skin burns. Causes Respiratory tract irritation. Harmful if swallowed or inhaled. Do not ingest. Do not get in eyes, on skin, or on clothing. Avoid breathing vapors, spray or mists. Use only with adequate ventilation. Keep container closed. Wash thoroughly after handling. --Diamond Shield Hard Surface Cleaner MSDS sheet contained the following: Section Two Hazards Identification: Statement of hazards: Caution. Causes eye and skin irritation. Primary route of exposure: Skin and eye contact are the principal routes of exposure to this product. Skin contact: skin contact may cause irritation. Eye Contact: Eye contact may cause irritation. Severity of action is highly dependent on contact time. Ingestion: If swallowed this product may cause irritation of mucous lining of the mouth, throat, esophagus or stomach. -- Lemon Eze cleaning product MSDS sheet contained the following: 2. Hazards Identification. Danger! Causes eye burns. Do not get in eyes. Wash thoroughly after handling. Corrosive to the eyes. Slightly irritating to the skin . --Stride Citrus HC 3 Neutral Cleaner MSDS sheet contained the following: 2. Hazards Identification. Precautionary statements. Causes serious eye irritation. Avoid contact with eyes, skin, and clothing. Wash affected areas thoroughly after handling. (MONTH) cause irritation to mouth, throat, and stomach . --Crew bathroom cleaner and scale remover MSDS sheet contained the following: 2. Hazards Identification. Danger harmful if swallowed. Causes Skin Irritation. Causes serious eye damage. Causes burns/serious damage to mouth throat, and stomach. Avoid contact with eyes, skin, and clothing . --Glance NA Glass and Multi Surface Cleaner Non Ammoniated MSDS sheet contained the following: 2. Hazards Identification. Warning. Causes serious eye irritation. Avoid contact with eyes, skin and clothing . --Virex II 256 one step disinfectant cleaner and deodorant; quat based disinfectant MSDS sheet contained the following: 2. Hazards Identification. Danger! Combustible liquid. Causes Skin Burns and serious eye damage. Harmful if Swallowed. Causes burns/serious damage to mouth, throat, and stomach. Avoid contact with eyes, skin and clothing. Keep away from flames and hot surfaces . --Baseboard wax stripped MSDS sheet contained the following: Danger! Extremely flammable aerosol. Causes Skin irritation. (MONTH) Cause allergic reaction. Causes serious eye irritation. --MST Apire BB (base board) Stripper MSDS sheet contained the following: Hazard Statement: Contains gas under pressure; may explode if heated. Causes severe skin burns and eye damage. --Stainless Steel Cleaner MSDS sheet contained the following: 2. Hazards Identification. Flammable Contents under pressure. Aerosol will be easily ignited by heat, spark, or flames. Harmful in contact with eyes. Prolonged exposure may cause chronic effects. --Pinex all purpose cleaner MSDS sheet contained the following: 2. Hazards Identification. Warning! Causes serious eye irritation and causes mild skin irritation. The director of Nursing (DON) was asked to provide a list of all residents who could potentially enter the unlocked supply closet and come in contact with the chemicals stored inside the closet. She indicated Resident #91, #26, #108 and #79 were all cognitively impaired and had the ability to independently open the supply closet door and come in contact with the chemicals stored in the closet. b) Resident #41 An observation on 03/06/17 at 11:00 a.m., in Resident #41's room, revealed bilateral quarter side rails were used. Both rails were loose when moved. By placing your hand on the rail and moving it, you could determine the rail was loose. It had a lot of movements back and forth. A staff interview, on 03/05/17 at 3:35 p.m., revealed Resident #41 had bilateral side rails for turning and repositioning in bed. A review of Resident #41's care plan revealed she had a physical functioning deficit related to: self-care impairment, mobility impairment due to history of hip fractures and generalized weakness. An intervention was listed as: bilateral 1/2 side rails to assist with self-turning and repositioning. At 3:05 p.m. at 3:20 p.m., a second observation with Licensed Practical Nurse (LPN) #18 and Assistant Director of Nursing Services (ADNS) #45 revealed the bilateral rails were loose. LPN #18 said she would have Specialist Maintenance 2 (SM2) #19 come and look at the rails. At 3:35 p.m. SM2 #19 came in Resident #41's room and tightened the rail on the left side of the bed. SM2 #19 was asked to tighten the right rail. SM2 #19 said these rails get worked lose from where the resident's pull on them. He confirmed both sides (left and right) needed tightened. c) Resident #9 An observation, on 03/06/17 at 9:48 a.m., revealed the resident had bilateral quarter side rails. The left-side rail was observed loose. The rail was observed to move from side to side when the surveyors had was placed on the rail. At 10:00 a.m., the surveyor informed SM2 #19 and Specialist Maintenance 1 (SM1) #8 that this resident's bed had side rails that were not tight. At 10:30 a.m., SM2 #19 and SM1 #8 confirmed the rails were loose and needed tightened. During a staff interview, on 03/05/17 at 3:42 p.m., with Registered Nurse #29 she confirmed Resident #9 had bilateral quarter side rails to her bed for mobility and positioning. A review of the resident's care plan revealed she had a physical functioning deficit related to self-care impairment and mobility impairment. The intervention stated, Bilateral half side rails for bed mobility and positioning per therapy suggestion. On 03/07/17 at 10:06 a.m., an interview with interim Executive Director (ED) #25 and SM1 #2 both said nursing staff can enter maintenance request via the computer, and these results are available to SM2 #19 for review. He also said the facility has a system that notifies them when a room needs cleaned thoroughly. SM2 #19 was asked what could happen if the rails were not tightened. He replied, They could fall off. d) Resident #79 During Stage 1 of the Quality Indicator Survey (QIS) at 1:59 p.m. on 03/05/16, the resident said nurse aide (NA) #52 and NA #41 were transferring her from the bed to her wheelchair. She said NA #52 picked her up and put her in the wheelchair. He was trying to drive off with my foot caught behind the wheel of the wheelchair, twisting my ankle. She said NA #41 saved her life by making NA #52 stop the wheelchair. She said my ankle would have been twisted off if it wasn't for NA #41. She said NA #41 must have told someone about the incident because NA #52 has been banned from her room. Resident #79 said NA #52 whispered in her ear, while she was screaming, Damn it, you need to let me be a man. The resident was unable to provide the date the incident occurred. Review of the reportable allegation of abuse/neglect to the proper state authorities found no reporting of the incident. An incident report form was completed on 02/15/17 at 3:25 p.m. The following is a description of the incident: Resident in shower room this afternoon c/o (complained of) injury to left ankle causing pain. Assessment of left ankle shows no trauma, bruising, swelling. When questioned resident reports no pain at this time. The family nurse practioner was notified. Resident states that during transfer on Saturday evening, 02/11/17 her left ankle was caught in the wheel of her wheelchair during a transfer. Resident did not c/o pain or discomfort at that time. The report was signed by Registered Nurse, (RN) #40. The incident was reported to RN #40 by NA #6. An x-ray was ordered of the left ankle. The second page of the incident report requires the following: Identify appropriate recommendations/interventions for each causal or contributing factor listed. Casual/contributing factors and observations specify recommendations/interventions taken. (May include information from witness interviews, medical record to prevent reoccurrence review, environmental observations, equipment, etc.). There was no information provided under this heading, concerning the incident. At 1:42 p.m. on 03/06/17, the director of nursing (DON) stated she had no further investigation of the incident on 02/15/17. The DON reviewed the resident's care plan and stated the resident does require the assistance of two staff members for transfers. She verified the incident report did not detail who was transferring the resident during the transfer or if two staff members were present during the transfer. At 1:45 p.m. on 03/06/17, the assistant DON, RN #35 verified there was no further investigation regarding the incident on 02/15/17. She stated NA #52, doesn't work on this resident's unit. She thought the resident had NA #52 confused with a NA the resident doesn't like. The DON and RN #35 denied anyone looked at who was providing care for the resident on 02/11/17, and any information to verify the resident was being transferred according to the care plan and physician's orders [REDACTED]. At 1:48 p.m. on 03/06/17, RN #40 was interviewed regarding the incident reported to her on 02/15/17. She said NA #6 called her to the shower room to look at the resident's ankle. She said the resident said she bumped her ankle, she never said anything about NA #52 doing anything to her. The X-Ray showed no negative findings. The resident said the incident happened on Saturday. RN #40 said the only male NA working with the resident on 02/11/17 was NA # 63 not NA #52. NA #6 was interviewed at 1:53 p.m. on 03/06/17. She said she told the unit charge nurse what the resident said, which is what is written on the incident report. She stated she looked at the resident's leg and ankle and did not see anything. At 3:45 p.m. on 03/06/17, NA #41 was interviewed by telephone with RN #35. RN #35 started by asking the NA if she knew Resident #79. NA #41 said she did. When RN #35 asked if she was aware of an incident involving Resident #79, she immediately said, I know what you are talking about. According to NA #41 she asked NA #52 to help her transfer the resident from her wheelchair to the bed. She said that during the transfer, the resident yelled out, she assisted the resident back to the wheelchair so she could investigate why the resident was yelling. She said the resident's ankle was behind the wheel of the wheelchair. She said she saw no injury to the resident's ankle. She told the resident she would get the nurse but the resident said she did not need the nurse. NA #41 said she told the nurse about the incident but she doesn't remember the nurse's name. She said NA #52 said something to the resident that made her mad but she doesn't remember what NA #52 said. She said the resident confuses NA #52 with another male N[NAME] RN #35 said she was making a reportable allegation to the proper state authorities. At 8:38 a.m. on 03/08/17, the incident was discussed with the administrator. No further information had been provided at the close of the survey, at 11:45 a.m. on 03/09/17, to verify the facility had investigated the incident when it occurred on 02/11/17. There was no information to determine if the resident was being transferred as directed by the care plan and no indication as to how the facility may have prevented future accidents during transfers.",2020-09-01
305,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,332,D,0,1,UN5811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of medication administration, reconciliation of the observed medication administration with medical records, staff interviews, and policy and procedures on administering medication, the facility failed to ensure it was free of a medication error rate of five (5) percent or greater. Two (2) errors were identified during thirty-two (32) observed opportunities, making the facility's medication error rate 6.25%. This affected one (1) of three (3) residents observed during medication administration observations. Resident identifiers: #3. Facility census: 81. Findings include: a) Resident #3 During the medication pass observation, on 03/07/17 at 8:43 a.m., Charge nurse-licensed practical nurse (CN-LPN) #50, was observed administering medications to Resident #3. Reconciliation of the observed medications administered with the resident's medical record revealed two (2) medication errors. Error #1: [MEDICATION NAME] 24 micrograms (mcg) give one capsule by mouth, one (1) time a day, every two (2) days related to constipation. This medication next dose is to be given at 9:00 a.m. on 03/08/17. Error #2: Disdol 50,000 units by mouth one (1) time a day every Thursday related to Vitamin D Deficiency. This medication is to be administered on Thursday 03/09/17. In an interview and review of the Medication Administration Record [REDACTED]. At 8:10 a.m. on 03/08/17, the Director of Nursing (DON) was made aware of the medication errors identified for Residents #3 during the medication administration observation. No further information provided. A review of the facility's policy on medication administration on 03/08/17 at 10:00 a.m., revealed the facility follows the five (5) rights: right resident, right drug, right dose, right route, right time, are applied for each medication being administered.",2020-09-01
306,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,356,C,0,1,UN5811,"Based on observation, and staff interview, the facilty failed to post the nurse staff posting information on 03/05/17. This was found during a random observation. This failed practice had the potential to affect all residents. Facility census: 81. Findings include: Observation on 03/05/17 at 10:20 a.m., found the nurse staff posting information up front near the main lobby. The date on the nurse staff posting form was 03/04/17. In an interview and review of the nurse staff posting form near the main lobby on 03/05/17 at 10:33 a.m., with registered nurse (RN) #29, she confirmed the posting on the wall was for 03/04/17. The NSRN stated that 03/05/17's nurse staff posting form should have been posted at 7:00 a.m. this morning.",2020-09-01
307,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,371,E,0,1,UN5811,"Based on observation and staff interview, the facility failed to ensure food items in the resident's pantry refrigerators were labeled and dated with the resident's name, the date the food item was placed in the refrigerator, and the date of discard. In addition, the facility failed to discard food items kept after the manufacturer use by date. This had the potential to affect more than a limited number of residents. Facility census: 81. Findings include: a) East wing-long hall pantry Observation of the East long hall pantry, during the initial tour of the facility, with nurse aide (NA) #33, at 10:20 a.m. on 03/05/17, found a bag of pineapple with Resident #99's name. The pineapple had no date to indicate when the item was placed in the refrigerator and no date of discard. A container of grapes, with no resident's name, had a manufacturer discard date of 03/04/17. A loaf of bread was found in the cabinet which was not sealed. Several slices of bread were out of the bag and were lying on the shelf. b) West wing-long hall pantry Tour of the West wing long hall pantry with Registered Nurse (RN) #40, at 10:35 a.m. on 03/05/17, found a cheeseburger with Resident's #65's name. There were no dates on the cheeseburger to indicate the date the cheeseburger was placed in the refrigerator and no date of discard. RN #40 placed the cheeseburger in the trash can.",2020-09-01
308,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,372,F,0,1,UN5811,"Based on observation and staff interview, the facility failed to ensure they maintained the garbage in a manner that would prevent the attraction of rodents and vermin. This practice had the potential to affect all residents. Facility Census: 81. Findings include The garbage dumpster area was observed on 03/05/17 at 10:10 a.m. The facility had three (3) dumpster's that contained bags of garbage. The lid of one (1) of the three (3) dumpsters was open. The third dumpster had a bags of garbage sitting on top of the closed lid with gloves and other debris noted on top and around the dumpster. On 03/05/17 at 10:30 a.m., during an interview with Cook #92. She stated the lids should be closed and the bag of garbage should be in the dumpster not on top of the dumpster lid. Nursing Home Administrator (NHA) informed of the opened and over flowing dumpsters on 03/05/17 at 11:15 a.m. No other information provided.",2020-09-01
309,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,412,D,0,1,UN5811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, and medical record review, the facility failed to ensure two (2) of three (3) residents reviewed for the care area of dental services, obtained dental services in a timely manner. Resident identifiers: #87 and #38. Facility census: 81. Findings include: a) Resident #87 During an interview with Resident #87, at 1:12 p.m. on 03/05/17, he said his teeth were hurting He said he needed to have his teeth pulled and was trying to, Get up there to get them pulled. He said he had seen a dentist but no one was helping him get the teeth pulled. He said, I have money and can pay for it. The resident also said he wanted a set of dentures. Observation found the resident had several missing teeth. Review of the resident's last full minimum data set (MDS), an annual with an assessment reference date (ARD) of 06/24/16, found the dental section was coded with obvious or likely cavity or broken natural teeth. Review of the care plan found the following problem: --At risk of dental problems related to some natural teeth loss, possible carious teeth. The goal associated with the problem was: --Will be free of complications related to dental/oral issues thru next evaluation. The approaches included: --Assistance with oral care as needed, --Inspect oral cavity for bleeding of gums or other issues, and --Refer to dental services as needed. An interview with the resident and Registered Nurse (RN) #35, the assistant director of nursing, at approximately 3:00 p.m. on 03/06/17, found the resident told RN #35 his teeth had been bothering him for about one year. He said, I have money to pay to get my teeth pulled and I can get an ambulance to go get them done. RN #35 said Employee #21 had scheduled the resident to see a dentist. She said the resident's responsible party had not followed up with the facility to make an appointment to get the resident's teeth extracted. At 4:15 p.m. on 03/06/17, Employee #21 said she had documentation she had been trying to get the responsible party to sign the resident's paper work so he could get his teeth extracted. She said the responsible party didn't think the resident really wanted his teeth pulled, he just wanted to get out of the facility for a while and go for an outing. She said the resident believed he would be hospitalized for [REDACTED]. She said the resident really doesn't understand he wouldn't be at the hospital. Employee #21 said the facility physician had already given clearance for the surgery. She (referring to the responsible party) is dragging her feet because she has to be there for the surgery. Observation found the referral for the oral surgeon was on the medical record unsigned by the responsible party. Employee #21 provided the following documentation: --(Name of responsible party had an appointment scheduled with this author on 05/06. She did not show. This author has tried on several occasions to reach her via phone, leaving messages with employees at the number provided. This author will sent a letter to her known address. A meeting needs to be made with the RP (responsible Party), Resident and SW (social worker) to discuss full mouth extractions and plan of care as discussed with Dr. (name of dentist) and this author for this resident. The note was dated 05/20/16. A second note dated 10/06/16, dental (name of oral surgeons) to mail paperwork to MPOA (medical power of attorney) to sign before consult to be scheduled. The MPOA has in the past (2x) asked for conference with this resident and author to discuss the plan of treatment ie: being without teeth for 12 months while gums heal but has not shown for either. Certified mail to be resent on 10/07 with request for meeting, copy to be on file with this author. The next note was dated 11/02/16, RP returned phone call stated she did not see it necessary to have extractions at this time. Employee #21 provided a copy of the dental consult, dated, 04/06/16, Patient presents with pain in upper and lower teeth. X-rays were faxed her from (name of hospital) .Exam and X-ray shows the need for extraction of all remaining upper teeth by the oral surgeon. Remaining lower teeth need scaling and root planing and [MEDICATION NAME]. He is in need of upper denture and a lower partial . A dental consult note dated 04/08/16, (name of Employee #21) called from Golden living stating that they received clearance/permission from family members to have teeth extracted by the oral surgeon for Pt. Filled out referral and emailed to (Name of facility with the oral surgeon) and they will call Golden Living with appointment. At 2:22 p.m. on 03/07/17, the director of nursing (DON) and RN #21 were asked to provide further evidence the responsible party was aware of the dental consult on 04/06/16 noting the resident was having pain and needed further dental services. They were asked what would be their next step if a responsible party did not respond to needed treatment. Also the permission for the dental work remained on the facility's medical record and the dentist note indicated the referral was emailed to the facility, not the responsible party. Review of the resident's annual minimum data set (MDS) with an assessment date (ARD) of 06/24/16 found the resident scored a 15 on the brief interview of mental status (BIMS). A score of 15 is the highest score obtainable and indicates the resident is cognitively intact. A health care surrogate was appointed for the resident on 07/17/15. On 03/07/17, Employee #3, was asked to provide a copy of the information sent to the responsible party of Resident #87. At 4:50 p.m., on 03/07/17, information was provided for another resident, not Resident #87, by the administrator. The administrator was asked about the 10/06/16, note which said the resident would be without teeth for a year until his gums healed. The administrator was unaware as to how that conclusion was determined and by whom. At 9:00 a.m. on 03/08/17, RN #21 said the facility had been in contact with the resident's responsible party and arrangements were being made to ensure the resident received dental services. b) Resident #38 Observation of the resident, at 3:22 p.m. on 03/05/17, during Stage 1 of the Quality Indicator Survey (QIS) found the resident has missing teeth. Review of the most recent annual MDS, with an ARD of 02/01/17, found the resident was coded as having obvious or likely cavity or broken natural teeth. Review of the documentation regarding dental services was provide on the afternoon of 03/07/17 by the DON. The following was documented in the facility progress notes: --02/09/16, Letter mailed in regards to dental exam. SASE (abbreviation unknown) with consent forms enclosed. Power of Attorney (POA) must be present for exam, eval. (evaluation) and X-Rays. POA to contact this author with availability for scheduling. --04/11/16, Certified letter mailed on this date by this author in regards to dental audit and suggestion that this resident to be seen by (name of dentist). A carbon copy of the letter in on file with this author. --04/25/16, Certified letter green card signed and returned to this author. No consent has been returned as to date. At 4:50 p.m. on 03/07/17, the administrator was asked what the facility did to follow up the the POA regarding the dental appointment scheduled. At 8:30 a.m. on 03/08/17, the administrator was unable to provide information on how the facility addressed the unresponsiveness of the responsible parties of Resident's #87 and #38. Both resident were determined to need dental services and the facility said neither responsible party had acted on getting the needed dental services. The guidance to surveyors directs, for Medicaid residents, the facility must provide the resident, without charge, all emergency dental services, as well as those routine dental services that are covered under the State plan. The administrator was unable to provide information the responsible parties of Resident's #87 and #38 were aware the dental services could be provided without cost to the resident.",2020-09-01
310,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,441,D,0,1,UN5811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and resident interview, the facility failed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection. The facility failed to maintain a sanitary environment for one (1) of 35 residents observed during Stage 1 of the Quality Indicator Survey (QIS). An observation revealed a large, dried yellowish-brown urine like substance underneath the resident's bed. Resident identifier: #9. Facility census: 81. Findings include: a) Resident #9 On 03/05/17 at 12:33 p.m., an observation made in Resident #9's room revealed a large stain of a brownish/yellow substance that was dried. The brownish/yellow substance covered the area underneath the resident's bed. It extended out one side of the bed and a little from the end of the resident's footboard. An observation also revealed the resident had a urinary catheter that hung on the side of the bed near the floor. Staff interview conducted, on 03/05/17 at 3:41 p.m., confirmed the resident had a urinary catheter due to [DIAGNOSES REDACTED] (impairment in motor sensory function or sensory function of the lower extremities. At 2:30 p.m. on 03/06/17, an observation revealed the brownish/yellow stain that was under the resident's bed on 03/05/17 was gone. Housekeeper #74 was observed cleaning in Resident #9's room. She said she had been asked to clean up urine from the floor under the resident's bed. She said a nurse aide had asked her to clean up the urine because the resident's catheter bag had been leaking. At 3:00 p.m. on 03/06/17, Registered Nurse (RN) #23 said she did not know about the stain under the resident's bed and did not know if the resident's catheter bag was leaking. At 3:39 p.m. on 03/06/17 Registered Nurse (RN) #23 said she went ahead and changed Resident #9's catheter bag. She said she did not know if it was leaking, but she went ahead and changed it anyway. An interview with Nurse Aide #65, on 03/06/17 at 3:44 p.m., revealed she had been in the resident's room earlier in the day and asked Housekeeper #74 to clean up the floor under the resident's bed. She said she did not know what was under the bed. She said it could have been urine, she was not sure. She was asked if she had seen the substance earlier in the day. She said it was possible that she had seen it when she was in the room in the morning, but she was not sure. During an interview with Resident #9, on 03/06/17 at 3:54 p.m., the resident said her catheter bag leaked often, and she had told the staff about it before. She said she knew when her catheter bag leaked because she could smell it. She indicated she had told the nursing staff earlier in the day, and they did not change the catheter bag, but did clean up the floor under her bed.",2020-09-01
311,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,505,D,0,1,UN5811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the attending physician of the results of a physician ordered Comprehensive Metabolic Panel (CMP) and a B-Type Natriuretic (excretion of sodium in urine) Peptide (BNP) for Resident #120. This was true for one (1) of three (3) residents reviewed for the care area of hospitalization during Stage 2 of the Quality Indicator Survey. Resident identifier: #120. Facility census: 81. Findings include: a) Resident #120 A review of Resident #120's medical record, at 3:13 p.m. on 03/06/17, found a physician's order dated 11/07/16 for a CMP and a BNP related to a [DIAGNOSES REDACTED]. Further review of the record found no results for the CMP and BNP nor was their any evidence the attending physician and/or Nurse Practitioner was notified of the results. At 8:39 a.m. on 03/07/17, the Director of Nursing was asked to provide the results of the CMP and BNP ordered on [DATE]. At 9:43 a.m. on 03/07/17, Registered Nurse (RN) #23 provided the results of the CMP and the BNP. These results indicated the lab was obtained on 11/08/16 and the results were reported to the facility on the same date. The results were not signed by the physician and/or Nurse Practitioner nor did the facility provide any evidence nursing staff had reported these results to the attending physician. A final interview with the DON, at 12:00 p.m. on 03/07/17, confirmed there was no evidence in the record the physician and/or Nurse Practitioner was notified of the results. She indicated the Nurse Practitioner was going to send over her notes and if they indicated she knew about the results she would provide them to the surveyor. At the time of exit on 03/08/17 at 11:45 a.m. no further information was provided.",2020-09-01
312,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,507,D,0,1,UN5811,"**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 physician ordered Comprehensive Metabolic Panel ( CMP) and B-Type Natriuretic (excretion of sodium in the urine) Peptide (BNP) in Resident #120's medical record. This was true for one (1) of three (3) residents reviewed for the care area of hospitalization during Stage 2 of the Quality Indicator Survey. Resident identifier: #120. Facility census: 81. Findings include: a) Resident #120 A review of Resident #120's medical record, at 3:13 p.m. on 03/06/17, found a physician's orders [REDACTED]. Further review of the record found no results for the CMP and BNP. At 8:39 a.m. on 03/07/17 the Director of Nursing (DON) was asked to provide the results of the CMP and BNP ordered on [DATE]. At 9:43 a.m. on 03/07/17, Registered Nurse (RN) #23 provided the results of the CMP and the BNP. These results indicated the lab was obtained on 11/08/16 and the results were reported to the facility on the same date. However; the print date on the results was 03/07/17 and at the top of the page was a fax line which indicated these results were faxed to the facility on [DATE] at 8:50 a.m. which is after they were requested by the surveyor. A final interview with the DON, at 12:00 p.m. on 03/07/17, confirmed they could not locate the original lab results in Resident #120's record and that is why they had to be faxed to the facility from the lab when requested.",2020-09-01
313,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,514,D,0,1,UN5811,"**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 complete and accurate. Resident #75's Medication Administration Record [REDACTED]. Resident #99 had an inaccurate [DIAGNOSES REDACTED]. Resident identifiers: #75 and #99. Facility census: 81. Findings include: a) Resident #75 Record review found the resident was admitted to the facility on [DATE]. He was discharged to the hospital on [DATE]. Review of the (MONTH) (YEAR), MAR found a physician's orders [REDACTED]. (If yes, go to notes.) Acceptable level of pain is 0. Nonpharmacological interventions include, but not limited to distraction, repositioning and food/drink. The MAR indicated [REDACTED].) On some occasions on the MAR indicated [REDACTED]. The DON confirmed the MAR indicated [REDACTED]. b) Resident #99 A review of Resident #99's discharge order on 03/07/17 at 3:30 p.m., found Resident #99's is receiving [MEDICATION NAME] (an anticoagulant) for deep-vein [MEDICAL CONDITIONS] [MEDICATION NAME]. A review of the resident's physician order [REDACTED].#99 is receiving [MEDICATION NAME] 5,000 units twice a day subcutaneously related to [MEDICAL CONDITIONS] of native coronary artery without [MEDICAL CONDITION] pectoris. On 03/07/17 at 3:45 p.m., the DON reviewed Resident #99's discharge and physician orders [REDACTED].#99.",2020-09-01
314,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2018-06-27,812,F,0,1,2RJB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to store, prepare and serve food in accordance with professional standards for food service safety in one of one kitchen and one of one main dining room. Specifically, the facility failed to ensure proper food temperatures throughout meal service; ensure proper thermometer use; dispose of expired foods; and ensure proper food handling techniques. This failed practice had the potential to affect all the residents of the facility. Facility census: 83. Findings included: a) Temperatures and thermometer use Cook #2 was observed on [DATE] from 10:47 AM until 12:47 PM, throughout lunch meal service. She prepared egg salad sandwiches with the egg salad observed out at room temperature from 10:47 AM through 11:07 AM. She placed the second pan of completed egg salad sandwiches into the walk-in at 11:07 AM. --At 11:25 AM, she poured a pitcher of ice into the water already present in 5 out of 6 wells of the steam table. The 5 wells were turned off to heat. At 11:36 AM, she placed one pan of egg salad sandwiches onto the steamtable. The bottom of the pan touched the ice in the well. The sandwiches were stacked up on top of each other. The macaroni salad was in a shallow pan. The bottom of the pan did not touch the ice in the bottom of the well. --At 11:46 AM, she started taking temperatures of the food items on the steam table. She placed a thermometer into the macaroni salad. She pushed the digital thermometer into the food item. The yellow plastic portion was also pushed into the food. --She placed another digital thermometer into the egg salad sandwich and pushed until the yellow plastic portion was touching the food. The egg salad sandwich measured 42 degrees Fahrenheidt (F). --At 11:51 AM, she placed a thermometer into the pureed macaroni salad with the plastic yellow portion pushed into the product. --At 11:52 AM, she placed a thermometer into the pureed egg salad sandwich with the yellow portion of the thermometer pushed into the product about 1/2 inch. --At 11:55 AM, the temperature of the coleslaw was taken and measured 42 degrees F. The coleslaw was stored in separate bowls, without temperature control. --By 12:43 PM, the staff was finished with meal service. The temperature of the coleslaw was 45 degrees F. The temperature of the macaroni salad was 50.5 degrees F. The temperature of the egg salad sandwich was 52 degrees F. While checking the temperature of these food items, the cook pushed several of the buttons on the digital thermometer. She was unsure as to what number she was supposed to be looking at for temperatures. Review of the food temperature documentation revealed food within proper temperatures with the exception the above meal observation. The temperatures were only documented at the beginning of service. The dietary district manager and the certified dietary manager (CDM) were interviewed on [DATE] at 3:53 PM. They stated this cook had worked there long enough to know how to take food temperatures. They acknowledged the improper practice. Resident #65 was interviewed on [DATE] at 10:47 AM. He stated the food was not at the right temperature. The food did not taste good. He usually ate his meals in his room. Review of the Food: Preparation policy, revised ,[DATE], revealed the dining services director/cook will be responsible for food preparation techniques which minimize the amount of time the food items are exposed to temperatures greater than 41 degrees and/or less than 135 degrees per state regulation. b) Expired foods The kitchen was observed on [DATE] at 8:14 AM. The tall refrigerator was observed to have had a 5-pound container of sour cream (,[DATE] full) with a best if used by date of [DATE]. The walk-in refrigerator was observed to have had a 5-pound container of sour cream, unopened, with a best if used by date of [DATE]. The kitchen was observed again on [DATE] at 10:47 AM. The tall refrigerator was observed to have had 4 one-quart containers of heavy whipping cream dated [DATE], by the manufacturer. The dietary staff dated the cream as received on [DATE]. The dietary district manager and the CDM were interviewed on [DATE] at 3:53 PM. They confirmed they used the manufacturers date as the use by date for expired foods. c) Touching ready-to-eat foods with bare hands The main dining room was observed on [DATE] at 12:25 PM throughout lunch service. The business office coordinator #48 was observed. She brought a plate with 2 sandwiches to resident #21. She touched one of the sandwiches to move to the side with her bare hand. She proceeded to hold the other sandwich with her bare hand while cutting the sandwich for the resident. The business office coordinator was interviewed on [DATE] at 3:21 PM. She stated she helped in the dining room every weekday. It had been a while since she had been trained on meal service. She was unsure as to what she should've done differently. Review of the Meal Distribution policy, revised ,[DATE], revealed proper food handling techniques to prevent contamination and temperature maintenance controls will be used for point-of-service dining.",2020-09-01
315,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2019-07-10,657,D,0,1,L7T111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to revise comprehensive care plans when residents experienced changes in condition. This was true for three (3) of 17 residents reviewed during the long-term care survey process. Resident #2's comprehensive care plan was not updated regarding medications. Resident #12's comprehensive care plan was not updated regarding urinary elimination. Resident #36's comprehensive care plan was not updated regarding nutrition. Resident identifiers: #2, #12, #36. Facility census: 72. Findings included: a) Resident #2 Review of Resident #2's comprehensive care plan revealed the following foci: - (Resident name) receives antidepressant medication ([MEDICATION NAME]) r/t (related to) depression, poor nutrition. - (Resident name) receives antipsychotic medications ([MEDICATION NAME]) r/t behavior management. Review of Resident #2's comprehensive care plan revealed she was not currently prescribed two (2) of the medications contained in the comprehensive care plan. [MEDICATION NAME] ([MEDICATION NAME]) was discontinued on 4/1/19. [MEDICATION NAME] (aripiprazole) was discontinued on 6/10/19. During an interview on 07/10/19 at 12:01 PM, the Director of Nursing agreed Resident #2 was no longer receiving [MEDICATION NAME] and [MEDICATION NAME], although she was care planned to receive these medications. No further information was provided prior to the survey exit conference. b) Resident #12 Upon observation on 07/08/19 at 1:00 PM, Resident #12 was noted to have an indwelling urinary catheter. Review of Resident #12's comprehensive care plan revealed the following focus: (Resident name) has bladder incontinence r/t (related to) Activity Intolerance, History of UTI (urinary tract infection), Impaired Mobility, Physical limitations, Obesity. Interventions were using disposable briefs, checking for incontinence, cleaning peri-area after each incontinence episode, handwashing before and after delivery of care, having call light within easy reach, observing for signs and symptoms of urinary tract infection, and observing for and reporting any possible causes of incontinence. Resident #12's comprehensive care plan also included the following focus: (Resident name) is at risk for Urinary Tract Infection r/t (related to) indwelling catheter, obesity, poor hygiene. Interventions were encouraging adequate fluid intake, giving antibiotic therapy as needed, having the call light within easy reach, observing vital signs and for signs and symptoms of urinary tract infection, obtaining laboratory testing, and assisting resident with hand washing after being toileted. Interventions related to maintaining the indwelling urinary catheter, such as daily catheter care, were not contained in the comprehensive care plan. During an interview on 07/09/19 at 2:00 PM, the Director of Nursing agreed Resident #12's comprehensive care plan contained a focus related to urinary incontinence, although he has an indwelling urinary catheter. She also agreed Resident #12's comprehensive care plan did not contain interventions relating to care of his indwelling urinary catheter. During an interview on 07/09/19 at 3:17 PM, the Administrator was informed of the above-described findings. No further information was provided prior to the survey exit conference. c) Resident #36 During the screening portion of the Long-Term Care Survey Process (LTCSP) on 07/08/19, Resident #36 appeared thin. On 07/10/19, a copy of Resident #36's weights for the past year as well as Resident #36's current care plan was requested for review. Per documentation provided by the facility, Resident #36's weights for the past year were as follows: 07/08/19 - 84.4 pounds 07/05/19 - 84.0 pounds 07/03/19 - 83.4 pounds 06/19/19 - 90.9 pounds 06/04/19 - 92.4 pounds 05/30/19 - 90.1 pounds 05/21/19 - 89.2 pounds 05/14/19 - 87.3 pounds 05/07/19 - 87.4 pounds 04/03/19 - 93.2 pounds 03/04/19 - 95.6 pounds 02/19/19 - 96.1 pounds 01/16/19 - 96.4 pounds 12/04/18 - 97.0 pounds 11/14/18 - 97.3 pounds 11/06/18 - 97.4 pounds 10/09/18 - 98.0 pounds 09/10/18 - 98.6 pounds 08/02/18 - 97.4 pounds A review of Resident #36's weight records during the survey revealed that Resident #36 had experienced a gradual and progressive weight loss trend since 09/10/18. Resident #36 had a slight weight gain for a few weeks after 05/14/19, after which point Resident #36's weight plummeted again, continuing the months-long progressive weight loss trend. During the survey, a review of Resident #36's care plan revealed the following nutritional goal, last revised on 01/09/19, (Resident's Name) will maintain adequate nutritional status as evidenced by maintaining weight with no s/s (signs/symptoms) of malnutrition through next review date. On 07/10/19 at 3:03 PM, the facility's Registered Dietitian (RD) agreed that the care plan goal had not been revised to reflect Resident #36's months-long weight loss trend and that maintaining weight was not an appropriate goal for someone with continued weight loss. The facility's Director of Nursing (DoN) was present during this interview and had no comment regarding the situation. No further information was provided prior to the survey exit conference.",2020-09-01
316,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2019-07-10,684,E,0,1,L7T111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, policy review, and staff interview, the facility failed to provide the necessary care and services to each resident to enable them to meet their highest practicable physical, mental and psychosocial well-being. Resident #8. #51, #15 and #12's medications were not administered within the scheduled timeframes on multiple occasions during a two (2) week period. This was a random opportunity for discovery. Resident identifiers: #8, #51, #15, and #12. Facility census: 72. Findings included: a) Resident #8 A review of Resident #8's Medication Administration Audit Report on 07/09/19 at 3:14 p.m. found Resident #8 was to receive the following medications scheduled to be administered at 9:00 AM: --Namzaric Capsule Extended Release 24 hour 28 --[MEDICATION NAME] --Multivitamin Tablet --[MEDICATION NAME] --Presser Vision [MEDICATION NAME] --Calcium D A review of the Medication Administration Audit Report for the previous two (2) weeks found these medications were administered outside of the scheduled timeframe on the following days: -- 06/26/19 all 9:00 a.m. medications were administered between 1:10 p.m. to 1:12 p.m. which was greater than four (4) hours 10 to 12 minutes after they were scheduled to be administered. -- 06/28/19 all 9:00 a.m. medications were administered between 10:28 a.m. to 10:29 a.m. which was almost one (1) hour and 28 to 29 minutes after they were scheduled to be administered. -- 06/29/19 all 9:00 a.m. medications were administered at 12:22 p.m. which was three (3) hours and 22 minutes after they were scheduled to be administered. -- 06/30/19 all 9:00 a.m. medications were administered at 11:53 a.m. which was two (2) hours and 53 minutes after they were scheduled to be administered. -- 07/02/19 all 9:00 a.m. medications were administered at 11:13 a.m. which was two (2) hours and 13 minutes after they were scheduled to be administered. -- 07/04/19 all 9:00 a.m. medications were administered at 11:20 a.m. which was two (2) hours and 20 minutes after they were scheduled to be administered. -- 07/05/19 all 9:00 a.m. medications were administered at 10:42 a.m. which was one (1) hour and 42 minutes after they were scheduled to be administered. -- 07/06/19 all 9:00 a.m. medications were administered between 12:29 p.m. and 12:32 p.m. which was three (3) hours and 29 to 32 minutes after they were scheduled to be administered. -- 07/07/19 all 9:00 a.m. medications were administered between 11:00 a.m. and 11:02 p.m. which was two (2) hours and 1 to 2 minutes after they were scheduled to be administered. Further review found Resident #8 had the following medications scheduled to be administered at 8:00 p.m. each night: --[MEDICATION NAME] .25 mg --[MEDICATION NAME] 20 mg --[MEDICATION NAME] 5 mg and --[MEDICATION NAME] 40 mg Further review of the Medication Administration Audit Report found these four (4) medications were administered outside the scheduled time frame: -- 06/29/19 all 9:00 p.m. medications were administered at 10:18 p.m. which was one (1) hour and 18 minutes after they were scheduled to be administered. -- 06/30/19 all 9:00 p.m. medications were administered at 10:16 p.m. was one (1) hour and 16 minutes after they were scheduled to be administered. -- 07/03/19 all 9:00 p.m. medications were administered on 07/04/19 at 12:04 a.m. which was three (3) hours and 4 minutes after they were scheduled to be administered. -- 07/04/19 all 9:00 p.m. medications were administered on 07/04/19 at 12:38 a.m. which was three (3) hours and 38 minutes after they were scheduled to be administered. -- 07/06/19 all 9:00 p.m. medications were administered at 10:40 p.m. which was one (1) hour and 40 minutes after they were scheduled to be administered. An interview with the Director of Nursing (DON) at 9:00 a.m. on 07/10/19 confirmed the medications are documented as administered outside of the scheduled time frames. She indicated they had started education with the nurses about documenting when they administer the medications instead of waiting until later in their shift. A review of the facility's policy titled Medication Administration found the following in regards to the time frames to administer medication, . 6. Administer medications within 60 minute of the scheduled time. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the facility. No further information was provided prior to the survey exit conference. b) Resident #51 An interview with Resident #51 during the Resident Council Meeting which was held on 07/09/19 at 10:30 a.m. revealed she does not get her medications timely. When asked if they receive the care they need without waiting for a long time? Resident #51 stated, It would be nice to get our 9:00 a.m. medication before 11:30 a.m. She indicated that she gets her medications late almost daily. A review of Resident #51's medical record at 3:00 p.m. on 07/09/19 found Resident #51 was ordered the following medications scheduled to be administered at 9:00 a.m. -- [MEDICATION NAME] -- Potassium -- [MEDICATION NAME] -- Natural Tears Solution -- Requip -- Fish Oil Capsule -- [MEDICATION NAME] Tablet -- [MEDICATION NAME] Sodium -- Aspirin Tablet -- [MEDICATION NAME] -- Folic Acid -- [MEDICATION NAME] ER Tablet -- [MEDICATION NAME] Powder 1 Packet -- [MEDICATION NAME] -- [MEDICATION NAME] Tablet Further review of the Medication Administration Audit Report found on the following occasions when Resident #51's 9:00 a.m. medications were given outside of the scheduled time frames: -- 06/28/19 all 9:00 a.m. medications were administered at 10:45 a.m. which was one (1) hour and 45 minutes after they were scheduled to be administered. -- 06/29/19 all 9:00 a.m. medications were administered between 11:23 a.m. and 11:24 a.m. which was two (2) hours and 23 to 24 minutes after they were scheduled to be administered. -- 06/30/19 all 9:00 a.m. medications were administered between 11:44 a.m. and 11:45 which was two (2) hour and 44 to 45 minutes after they were scheduled to be administered. -- 07/02/19 all 9:00 a.m. medications were administered between 11:58 a.m. and 11:59 which was two (2) hour and 58 to 59 minutes after they were scheduled to be administered. -- 07/04/19 all 9:00 a.m. medications were administered between 12:49 p.m. and 12:50 p.m. which was three (3) hour and 49 to 50 minutes after they were scheduled to be administered. -- 07/05/19 all 9:00 a.m. medications were administered at 11:10 a.m. which was two (2) hours and 10 minutes after they were scheduled to be administered. -- 07/07/19 all 9:00 a.m. medications were administered between 11:12 a.m. and 11:21 which was two (2) hours and 12 to 21 minutes after they were scheduled to be administered. -- 07/08/19 all 9:00 a.m. medications were administered at 10:39 a.m. which was one (1) hour and 39 minutes after they were scheduled to be administered. Resident #51 was also scheduled to receive the following medications at 1:00 p.m.: -- [MEDICATION NAME] -- [MEDICATION NAME] -- Natural Balance Tears Solution On the following occasions Resident #51's medication scheduled at 1:00 p.m. was administered outside of the scheduled administration time: -- 07/06/19 all 1:00 p.m. medications were administered between 4:28 p.m. and 4:35 p.m. which was three (3) hours and 28 to 35 minutes after they were scheduled to be administered. Resident #51 was also scheduled the following medications to be administered at 9:00 p.m.: -- [MEDICATION NAME] Capsule -- [MEDICATION NAME] -- Fish Oil -- [MEDICATION NAME] Capsule -- [MEDICATION NAME] -- [MEDICATION NAME] -- [MEDICATION NAME] -- [MEDICATION NAME] On the following occasions Resident #51's 9:00 p.m. medications were administered outside of the scheduled time frames: -- 06/25/19 all 9:00 p.m. medications were administered between 10:22 p.m. and 10:25 p.m. which was one (1) hour and 22 to 25 minutes after they were scheduled to be administered. -- 06/27/19 all 9:00 p.m. medications were administered at 10:45 p.m. which was one (1) hour and 45 minutes after they were scheduled to be administered. -- 06/29/19 all 9:00 p.m. medications were administered at 9:57 p.m. and 10:05 p.m. which was one (1) hour and 57 minutes and two (2) hours and 5 minutes after they were scheduled to be administered. -- 07/01/19 all 9:00 p.m. medications were administered between 9:29 p.m. and 9:32 p.m. which was one (1) hour and 29 to 32 minutes after they were scheduled to be administered. -- 07/02/19 all 9:00 p.m. medications were administered between 9:53 p.m. and 9:56 p.m. which was one (1) hour and 53 to 56 minutes after they were scheduled to be administered. -- 07/03/19 all 9:00 p.m. medications were administered between 9:35 p.m. and 9:46 p.m. which was one (1) hour and 35 to 46 minutes after they were scheduled to be administered. -- 07/06/19 all 9:00 p.m. medications were administered between 10:15 p.m. and 10:18 p.m. which was two (2) hour and 53 to 56 minutes after they were scheduled to be administered. -- 07/07/19 all 9:00 p.m. medications were administered between 10:22 p.m. and 10:26 p.m. which was two (2) hours and 22 to 26 minutes after they were scheduled to be administered. -- 07/08/19 all 9:00 p.m. medications were administered between 9:23 p.m. and 9:28 p.m. which was one (1) hour and 23 to 28 minutes after they were scheduled to be administered. An interview with the Director of Nursing (DON) at 9:00 a.m. on 07/10/19 confirmed the medications are documented as administered outside of the scheduled time frames. She indicated they had started education with the nurses about documenting when they administer the medications instead of waiting until later in their shift. A review of the facility's policy titled Medication Administration found the following in regards to the time frames to administer medication, . 6. Administer medications within 60 minute of the scheduled time. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the facility. On 07/10/19 at 11:54 AM, the facility's Director of Nursing (DoN) was notified of the above information. She stated, Okay. No further information was provided prior to the survey exit conference. c) Resident #15 A review of Resident #15's Medication Administration Audit Report found the resident was to receive the following medications scheduled to be administered at 9:00 AM: - [MEDICATION NAME] HCL tablet, give by mouth two (2) times a day related to type 2 diabetes mellitus without complications - Cardiazem LA tablet extended release 24 hour 380 mg, givve one (1) tablet by mouth one (1) time a day related to essential (primary) hypertension - [MEDICATION NAME] tablet 40 mg, give one (1) tablet by mouth one (1) time a day related to essential (primary) hypertension - [MEDICATION NAME] tablet, 50 mg, give 1.5 tablet by mouth two (2) times a day related to essential (primary) hypertension - [MEDICATION NAME] HCL tablet 100 mg, give one (1) tablet by mouth three (3) times a day related to essential (primary) hypertension - [MEDICATION NAME] 40 mg, give one (1) tablet by mouth one (1) time a day related to unspecified diastolic (congestive) heart failure - Omega-3 capsule 100 mg, give one (1) capsule by mouth one (1) time a day for supplement - [MEDICATION NAME] HCL tablet 50 mg, give one (1) tablet by mouth three (3) times a day for pain - [MEDICATION NAME] tablet, give 20 mg by mouth one (1) time a day related to [DIAGNOSES REDACTED] vulgaris - [MEDICATION NAME] tablet 25 mg, give 25 mg by mouth every 12 hours for itching related to [DIAGNOSES REDACTED] vulgaris - [MEDICATION NAME] Chloride tablet 5 mg, give one (1) tablet by mouth two (2) times a day related to other specified disorders of bladder - Vitamin B12 tablet, give 500 mg by mouth one (1) time a day related to disorder of the skin and subcutaneously tissue, unspecified The facility's policy entitled 'Medication Administration' stated, Administer medications within 60 minutes of the scheduled time. Further review of the report found the medications were documented as administered outside of the scheduled time frame on the following days: - 06/25/19: the medications were administered between 1:30 PM and 1:31 PM, which was over four (4) and a half hours after they were scheduled to be administered. - 06/26/19: the medications were administered at 11:34 AM which was over two (2) and a half hours after they were scheduled to be administered. - 06/29/19: the medications were administered at 9:45 PM, which was over twelve and a half hours after they were scheduled to be administered. - 07/04/19: the medications were administered at 7:42 PM, which was over ten and a half hours after they were scheduled to be administered. - 07/06/19: the medications were administered between 12:05 PM and 12:06 PM, which was over three (3) hours after they were scheduled to be administered. (Except [MEDICATION NAME], which was documented as given at 8:07 AM) A review of Resident #15's Medication Administration Audit Report found the resident was to receive the following medications scheduled to be administered at 1:00 PM: - [MEDICATION NAME] HCL tablet 100 mg, give one (1) tablet by mouth three (3) times a day related to essential (primary) hypertension - [MEDICATION NAME] HCL tablet 50 mg, give one (1) tablet by mouth three (3) times a day for pain Further review of the report found the medications were documented as administered outside of the scheduled time frame on the following days: - 06/25/19: the medications were administered at 4:05 PM, which was over three (3) hours after they were scheduled to be administered. - 06/26/19: the medications were administered at 5:45 PM, which was over four (4) and a half hours after they were scheduled to be administered. - 06/29/19: the medications were administered at 9:45 PM, which was over eight (8) and a half hours after they were scheduled to be administered. - 07/01/19: the medications were administered at between 6:28 PM and 6:29 PM, which was almost five (5) and a half hours after they were scheduled to be administered. - 07/02/19: the medications were administered at between 6:57 PM and 6:58 PM, which was almost six (6) hours after they were scheduled to be administered. - 07/04/19: the medications were administered at 7:42 PM, which was over six (6) and a half hours after they were scheduled to be administered. A review of Resident #15's Medication Administration Audit Report found the resident was to receive the following medications scheduled to be administered at 9:00 PM: - [MEDICATION NAME] HCL tablet, give by mouth two (2) times a day related to type 2 diabetes mellitus without complications - [MEDICATION NAME] tablet, 50 mg, give 1.5 tablet by mouth two (2) times a day related to essential (primary) hypertension - [MEDICATION NAME] HCL tablet 100 mg, give one (1) tablet by mouth three (3) times a day related to essential (primary) hypertension - [MEDICATION NAME] HCL tablet 50 mg, give one (1) tablet by mouth three (3) times a day for pain - [MEDICATION NAME] tablet 25 mg, give 25 mg by mouth every 12 hours for itching related to [DIAGNOSES REDACTED] vulgaris - [MEDICATION NAME] Chloride tablet 5 mg, give one (1) tablet by mouth two (2) times a day related to other specified disorders of bladder - [MEDICATION NAME] HCL capsule 2 mg, give 1 capsule by mouth at bedtime related to essential (primary) hypertension - [MEDICATION NAME] solution 100 unit/ml, inject 30 unit subcutaneuosly at bedtime related to type 2 diabetes mellitus without complications Further review of the report found the medications were documented as administered outside of the scheduled time frame on the following day: - 07/04/19: the medications were administered at 1:54 AM, which was almost five (5) hours after they were scheduled to be administered. An interview with the Director of Nursing (DON) at 9:00 a.m. on 07/10/19 confirmed the medications are documented as administered outside of the scheduled time frames. She indicated they had started education with the nurses about documenting when they administer the medications instead of waiting until later in their shift. On 07/10/19 at 11:54 AM, the facility's Director of Nursing (DoN) was notified of the above information. She stated, Okay. No further information was provided prior to the survey exit conference. d) Resident #12 A review of Resident #12's Medication Administration Audit Report found the resident was to receive the following medication scheduled to be administered at 7:30 AM: - [MEDICATION NAME] Solution Pen-Injector 100 units/ml (Insulin [MEDICATION NAME]), inject 18 units subcutaneously before meals for diabetes mellitus The facility's policy entitled 'Medication Administration' stated, Administer medications within 60 minutes of the scheduled time. Further review of the report found this medication was documented as administered outside of the scheduled time frame on the following days: - 06/25/19: the medication was administered at 9:29 AM, which was almost two (2) hours after it was scheduled to be administered. - 06/26/19: the medication was administered at 5:37 PM, which was over 10 hours after it was scheduled to be administered. - 06/29/19: the medication was administered at 12:23 PM, which almost five (5) after it was scheduled to be administered. - 07/04/19: the medication was administered at 4:55 PM, which nine (9) after it was scheduled to be administered. A review of Resident #12's Medication Administration Audit Report found the resident was to receive the following medications scheduled to be administered at 9:00 AM: - Vitamin D tablet ([MEDICATION NAME]), give 1000 mg by mouth two (2) times a day related to vitamin D deficiency, unspecified - Losartan Potassium tablet, give 100 mg by mouth one time a day related to essential (primary) hypertension - [MEDICATION NAME] solution 0.02%, 2.5 ml inhale orally four (4) times a day related to [MEDICAL CONDITION], unspecified - [MEDICATION NAME] tablet 10 mg, give 10 mg by mouth one (1) time a day related to essential (primary) hypertension - [MEDICATION NAME] Chloride tablet, give 5 mg by mouth three (3) times a day related to other specified disorders of the bladder - Ezetimibe tablet, give 5 mg by mouth one (1) time a day related to [MEDICAL CONDITION], unspecified - [MEDICATION NAME] capsule ER 24 hour sprinkle, give 50 mg by mouth one (1) time a day related to essential (primary) hypertension - Fish oil capsule 1000 mg (Omega-3 Fatty Acids), give 1000 mg by mouth one (1) time a day related to [MEDICAL CONDITIONS] of native coronary artery without [MEDICAL CONDITION] pectoris - [MEDICATION NAME] tablet ([MEDICATION NAME]), give 40 mg by mouth one (1) time a day related to unspecified diastolic (congestive) heart failure - Multivitamin tablet (multiple vitamin), give one (1) tablet by mouth one time a day for supplement - [MEDICATION NAME] HCL tablet, give 1000 mg by mouth two (2) times a day related to type 2 diabetes mellitus without complications Further review of the report found the medications were documented as administered outside of the scheduled time frame on the following days: - 06/25/19: the medications were administered between 2:16 PM and 2:17 PM, which was over five (5) hours after they were scheduled to be administered. - 06/26/19: the medications were administered between 5:36 PM and 5:37 PM, which was over eight (8) and a half hours after they were scheduled to be administered. - 06/29/19: the medications were administered at 12:24 PM, which was over three (3) hours after they were scheduled to be administered. - 07/04/19: the medications were administered between 4:55 PM and 4:57 PM, which was almost eight (8) hours after they were scheduled to be administered. A review of Resident #12's Medication Administration Audit Report found the resident was to receive the following medication scheduled to be administered at 11:30 AM: - [MEDICATION NAME] Solution Pen-Injector 100 units/ml (Insulin [MEDICATION NAME]), inject 18 units subcutaneously before meals for diabetes mellitus Further review of the report found the medication was documented as administered outside of the scheduled time frame on the following days: - 06/26/19: the medication was administered at 5:37 PM, which was over six (6) hours after it was scheduled to be administered. - 07/04/19: the medication was administered at 4:56 PM, which was over five (5) hours after it was scheduled to be administered. A review of Resident #12's Medication Administration Audit Report found the resident was to receive the following medications scheduled to be administered at 1:00 PM: - [MEDICATION NAME] solution 0.02%, 2.5 ml inhale orally four (4) times a day related to [MEDICAL CONDITION], unspecified - [MEDICATION NAME] Chloride tablet, give 5 mg by mouth three (3) times a day related to other specified disorders of the bladder Further review of the report found the medications were documented as administered outside of the scheduled time frame on the following days: - 06/26/19: the medications were administered at 5:38 PM, which was over four (4) and a half hours after they were scheduled to be administered. - 07/02/19: the medications were administered at 5:35 PM, which was over four (4) and a half hours after they were scheduled to be administered. - 07/04/19: the medications were administered at 4:56 PM, which was almost three (3) and a half hours after they were scheduled to be administered. A review of Resident #12's Medication Administration Audit Report found the resident was to receive the following medications scheduled to be administered at 4:30 PM: - [MEDICATION NAME] Solution Pen-Injector 100 units/ml (Insulin [MEDICATION NAME]), inject 18 units subcutaneously before meals for diabetes mellitus - Insulin NPH (Human) ([MEDICATION NAME]) suspension 100 unit/ml, inject 75 units subcutaneously two (2) times a day related to type 2 diabetes mellitus without complications Further review of the report found the medication was documented as administered outside of the scheduled time frame on the following days: - 06/29/19: the medications were administered at 12:40 AM on 06/30/19, which was over eight (8) hours after they were scheduled to be administered. - 06/30/19: the medications were administered between 9:29 PM and 9:31 PM, which was five (5) hours after they were scheduled to be administered. - 07/02/19: NPH insulin was administered at 10:04 PM, which was five (5) and a half hours after it was scheduled to be administered. A review of Resident #12's Medication Administration Audit Report found the resident was to receive the following medications scheduled to be administered at 5:00 PM: - [MEDICATION NAME] solution 0.02%, 2.5 ml inhale orally four (4) times a day related to [MEDICAL CONDITION], unspecified - [MEDICATION NAME] Chloride tablet, give 5 mg by mouth three (3) times a day related to other specified disorders of the bladder Further review of the report found the medications were documented as administered outside of the scheduled time frame on the following days: - 06/29/19: the medications were administered at 12:41 AM on 06/30/19, which was over seven (7) hours after they were scheduled to be administered. - 06/30/19: the medications were administered at 9:30 PM, which was four (4) and a half hours after they were scheduled to be administered. A review of Resident #12's Medication Administration Audit Report found the resident was to receive the following medications scheduled to be administered at 9:00 PM: - Vitamin D tablet ([MEDICATION NAME]), give 1000 mg by mouth two (2) times a day related to vitamin D deficiency, unspecified - [MEDICATION NAME] solution 0.02%, 2.5 ml inhale orally four (4) times a day related to [MEDICAL CONDITION], unspecified - [MEDICATION NAME] Chloride tablet, give 5 mg by mouth three (3) times a day related to other specified disorders of the bladder - [MEDICATION NAME] tablet, give 88 mcg by mouth at bedtime related to hypertension - [MEDICATION NAME] HCL tablet 50 mg, give 50 mg by mouth at bedtime for [MEDICAL CONDITION] - [MEDICATION NAME] Sodium tablet, give 13 mg by mouth at bedtime related to [DIAGNOSES REDACTED] - [MEDICATION NAME] tablet 20 mg, give 20 mg by mouth at bedtime related to major [MEDICAL CONDITION], recurrent, unspecified - [MEDICATION NAME] tablet, give 600 mg by mouth at bedtime related to pain, unspecified Further review of the report found the medications were documented as administered outside of the scheduled time frame on the following day: - 07/03/19: the medications were administered at 4:42 AM on 07/04/19, which was over seven (7) and a half hours after they were scheduled to be administered. An interview with the Director of Nursing (DON) at 9:00 a.m. on 07/10/19 confirmed the medications are documented as administered outside of the scheduled time frames. She indicated they had started education with the nurses about documenting when they administer the medications instead of waiting until later in their shift. On 07/10/19 at 11:54 AM, the facility's Director of Nursing (DoN) was notified of the above information. She stated, Okay. No further information was provided prior to the survey exit conference.",2020-09-01
317,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2019-07-10,686,D,0,1,L7T111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This was true for one (1) of one (1) residents reviewed for the care area of Pressure Ulcers. Resident identifier: #222. Facility census: 72. Findings included: a) Resident #222 A review of Resident #222 medical record at 9:36 a.m. on 07/09/19 found Resident #222 was admitted to the facility on [DATE] in the evening hours. Further review of the record found a Head to Toe Skin Check dated 06/28/19 at 8:12 p.m. which was completed by Registered Nurse (RN) #54. This form indicated Resident #222 had a Pressure ulcer to her Coccyx and her left heel. However the sections were the length, width, depth, and pressure ulcer stage were to be documented was left blank and not completed. Further review of the medical record found an Admission Data Collection Assessment which was completed on 07/01/19. The assessment was created by RN #59 and revised by RN #54. This assessment under section 7. Physical Examination: Skin Integrity [NAME] Skin Conditions found Resident #222 had a pressure ulcer to her coccyx and her left heel. The sections to record the length, width, depth and pressure ulcer stage was again left blank on this assessment. The medical record also contained two (2) Skin - Weekly Pressure Ulcer Record one for each wound previously identified. The Weekly Pressure Ulcer Record for the Left Heel was completed on 07/04/19 at 9:05 a.m. by the Wound Care RN #32 this assessment indicated the date of onset for this wound was 06/28/19 and the resident was admitted with this wound. Wound Care RN #32 measured the wound and staged the pressure ulcer and documented the wound was 4.2 centimeters (CM) long, 3.6 cm wide, .1 cm deep and was a Stage II pressure ulcer. This was the first time since the residents admission on 06/28/19 the measurements of the wound and the stage had been assessed. The Weekly Pressure Ulcer Record for the Coccyx was completed on 07/04/19 at 9:13 a.m. by Wound Care RN #32 this assessment indicated the date of onset for this wound was 06/28/19 and the resident was admitted with this wound. Wound Care RN #32 measured the wound and staged the pressure ulcer and documented the wound was 2.5 cm long, 1.1 cm wide, .1 cm deep and was a Stage II pressure ulcer. This was the first time since the residents admission on 06/28/19 the measurements of the wound and the stage had been assessed. A review of the Treatment Administration Record (TAR) for Resident #222 since the time of admission until present found the pressure ulcer to the coccyx and the pressure ulcer to the left heel were not treated until 07/05/19. A review of the Physician order [REDACTED].#222's pressure ulcers: --wound to coccyx: cleanse wound with normal saline. pat dry. apply skin prep peri wound. apply puracol collagen dressing to wound bed. cover with bordered foam dressing. change q MWF (Every Monday, Wednesday, and Friday) and prn (as needed). This order had an order date of 07/03/19 with a start date of 07/05/19. -- wound to left heel: cleanse wound with normal saline. pat dry. apply skin prep peri wound. apply silver alginate dressing to wound bed. cover with bordered foam dressing. change q MWF (every Monday, Wednesday, and Friday) and prn (as needed). This order had an order date of 07/03/19 with a start date of 07/05/19. There were no orders for the treatment of [REDACTED]. An interview with the Wound Care RN #32 at 10:14 a.m. on 07/10/19 confirmed Resident #222 was admitted to the facility on [DATE] at which time the pressure ulcer to the coccyx and to the left heel was identified. He agreed the wound was not measured or staged until he returned to work on 07/03/19. He also agreed the wound had no treatment orders in place until he returned to work on 07/03/19. Wound Care RN #32 stated that typically wounds are measured, staged, and a treatment is ordered within the first 24 hours after admission. He indicated that he was off from work for a few days and that is why there was a delay. He agreed that someone should have done the measuring, staging and treatment orders in his absence. During an Interview with the Director of Nursing (DON) at 10:28 a.m. on 07/10/19 the above findings were reviewed. She agreed that someone should have measured, staged and treated the pressure ulcers prior to 07/03/19 in the absence of Wound Care RN #32. She stated that she would review the record and if she found any additional information she would provide it. At the time of exit no additional was provided. An additional interview with Wound Care RN #32 at 11:04 a.m. on 07/10/19 revealed he did treat Resident # 222's pressure ulcers on 07/03/19. He indicated that he did the treatment before he put the order in and it was not documented in the medical record that it was performed. No further information was provided prior to the survey exit conference.",2020-09-01
318,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2019-07-10,690,D,0,1,L7T111,"**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 with an indwelling urinary catheter received appropriate care and services. Daily catheter care was not documented for Resident #12. This was true for one (1) of one (1) resident reviewed for the care area of urinary catheter. Resident identifier: #12. Facility census: 72. Findings included: a) Resident #12 Upon observation on 07/08/19 at 1:00 PM, Resident #12 was noted to have an indwelling urinary catheter. Resident #12 had an order written [REDACTED]. The catheter was to be changed as needed for dysfunction. Resident #12's current orders did not contain orders for daily catheter care. Proper care and cleaning of the catheter, the insertion site, and the urine drainage bag are important to help prevent infection. Resident #12's comprehensive care plan included the following focus: (Resident name) is at risk for Urinary Tract Infection r/t (related to) indwelling catheter, obesity, poor hygiene. Interventions were encouraging adequate fluid intake, giving antibiotic therapy as needed, having the call light within easy reach, observing vital signs and for signs and symptoms of urinary tract infection, obtaining laboratory testing, and assisting resident with hand washing after being toileted. Interventions related to maintaining the indwelling urinary catheter, such as daily catheter care, were not contained in the comprehensive care plan. During an interview on 07/09/19 at 2:00 PM, the Director of Nursing agreed Resident #12's comprehensive care plan did not contain interventions relating to care of his indwelling urinary catheter. During an interview on 07/09/19 at 3:17 PM, the Administrator was informed of the above-described findings. She was also informed Resident #12's current orders did not contain orders for daily catheter care. During an interview on 07/09/19 at 4:00 PM, Corporate Registered Nurse (RN) #83 stated daily catheter care for Resident #12 was not specifically documented on the Documentation Survey Report used by Nursing Assistants to record care provided. However, daily bathing activity and bladder elimination was documented on the Documentation Survey Report. Corporate RN #83 stated she believed daily catheter had been performed at these times. She added the task Catheter care with soap and water, rinse and pat dry to the Documentation Survey Report. No further information was provided prior to the survey exit conference.",2020-09-01
319,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2019-07-10,692,D,0,1,L7T111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review, staff interview, and review of additional documents provided by the facility, the facility failed to ensure residents maintained acceptable parameters of nutritional status by failing to provide diets as ordered and to monitor and address weight loss consistently and timely. This deficient practice was found for two (2) of four (4) residents reviewed for the care area of nutrition. Resident identifiers: #36, #23. Facility census: 72. Findings included: a) Resident #36 During the screening portion of the Long-Term Care Survey Process (LTCSP) on 07/08/19, Resident #36 appeared thin. On 07/10/19, a copy of Resident #36's weights for the past year as well as all documentation regarding Resident #36 from the facility's Registered Dietitian (RD) for the past year was requested from the facility's Director of Nursing (DoN). Additionally, a copy of the facility's weight management policy along with Resident #36's orders was requested. Per documentation provided by the facility, Resident #36's weights for the past year were as follows: 07/08/19 - 84.4 pounds 07/05/19 - 84.0 pounds 07/03/19 - 83.4 pounds 06/19/19 - 90.9 pounds 06/04/19 - 92.4 pounds 05/30/19 - 90.1 pounds 05/21/19 - 89.2 pounds 05/14/19 - 87.3 pounds 05/07/19 - 87.4 pounds 04/03/19 - 93.2 pounds 03/04/19 - 95.6 pounds 02/19/19 - 96.1 pounds 01/16/19 - 96.4 pounds 12/04/18 - 97.0 pounds 11/14/18 - 97.3 pounds 11/06/18 - 97.4 pounds 10/09/18 - 98.0 pounds 09/10/18 - 98.6 pounds 08/02/18 - 97.4 pounds According to the documents provided by the facility, Resident #36 had been assessed by the RD two (2) times in the past year. A full Nutrition RD Assessment had been completed on 12/05/18 and a Nutrition Note had been completed on 05/14/19. A review of Resident #36's weight records revealed that Resident #36 had experienced a gradual and progressive weight loss trend since 09/10/18 which was not identified by the RD until eight (8) months later on 05/14/19. Per the weight records, Resident #36 had a slight weight gain for a few weeks after 05/14/19, after which point Resident #36's weight plummeted again, continuing the months-long progressive weight loss trend. During the survey, a review of the facility's Weight Management policy, last revised (MONTH) (YEAR), found that Weekly At Risk Review Meetings will be conducted on each resident with weight loss until the IDT (Interdisciplinary Team) determines weight has stabilized and can discontinue from weekly review. The policy also stated that residents with insidious weight loss would be identified using a Weights & Vitals Exception Report that would be reviewed at the morning meeting either the day of or the day before the Weight At Risk Review Meeting. Per the policy, Insidious weight loss refers to a gradual, unintended, progressive weight loss over time. On 07/10/19 at 3:04 PM, the above information was discussed with the facility's Certified Dietary Manager (CDM), RD, Administrator, DoN, and Corporate Registered Nurse (RN) #83. These individuals stated that each resident with weight loss was discussed in a weekly IDT meeting held on each Wednesday. They added that the meeting had been cancelled last week, but that Resident #36's weight loss had been addressed in a binder that was not part of the medical record. When the above individuals were asked why the information in this binder was not added to the medical record for Resident #36, the DoN stated that just because the information was not present in the format that this surveyor was looking for, that didn't mean the weight loss was not addressed. The DoN then stated that a decision had been made as of 07/05/19 to stop using the binder as the sole source of information regarding weekly weight reviews and start putting the information regarding weekly weight meetings in the medical record. The RD repeatedly stated, I'm only here on Wednesdays, and added that she would address the weight loss that day (07/10/19). A copy of the information from the aforementioned binder regarding Resident #36's weight loss was requested from the facility's Administrator on 07/10/19 at 3:20 PM. At that time, the Administrator stated in direct contradiction of the staff's statements above that there was no information regarding Resident #36's weight loss in the binder, but that the weight loss would have been discussed that day (07/10/19) had surveyors not been in the building. At that time, a Performance Improvement Plan (PIP) regarding weight monitoring was voluntarily provided for review by the Administrator. The PIP indicated that a problem had been discovered with weights in (MONTH) 2019, four (4) months prior to the survey and during Resident #36's progressive weight loss trend. The PIP stated that, as a monitoring procedure, the DoN or designee would review all weight alerts in the electronic medical record daily during morning clinical meeting to identify residents with weight changes. On 07/10/19 at 3:45 PM, the facility's RD and CDM provided a new nutrition note completed that day (07/10/19) for review, along with a typed schedule indicating that Resident #36's weight was scheduled to be discussed with the IDT on 07/10/19. In the Nutrition Note, the RD acknowledged that Resident #36 had a BMI (body mass index) indicating underweight status, a weight loss trend, and a significant weight loss of 8.7 percent over the past 30 days. The RD documented that Resident #36 had poor to fair meal intakes and overall good acceptance of a supplement with occasional poor acceptance. The RD did not calculate Resident #36's estimated nutrient needs in the note, nor did the RD address whether Resident #36 was meeting their nutritional needs. The RD recommended to continue the current nutritional plan of care with no changes and recommended that Resident #36 begin taking [MEDICATION NAME] (an antidepressant medication) to stimulate appetite. On 07/10/19 at 4:05 PM, the facility's DoN and Corporate RN #83 stated that a weekly weight meeting had been held on 07/05/19, after they had previously stated that the meeting for that week had been cancelled. They added that not all the notes from the meeting on 07/05/19 had been entered in the medical records of the residents discussed. No further information was provided prior to the survey exit conference. b) Resident #23 During a review of medical records it was revealed that Resident #23 was diagnosed with [REDACTED]. Resident #23 was noted to be losing weight: -On 01/16/2019, Resident #23 weighed 173 pounds -On 07/03/2019, Resident #23 weighed 143 pounds which is a -17.34 % Loss. -On 04/03/2019, the resident weighed 158 pounds -On 07/03/2019, the resident weighed 143 pounds which is a -9.49 % Loss. On 01/22/19 Resident #23 was sent out to a local hospital. According to the nursing notes it was due to having a [MEDICAL CONDITION]. He did not return to the facility until 02/20/19. While out of the facility he had surgery to remove his gallbladder, at which time a feeding tube and a t-tube (used to drain bile) were inserted. Resident #23 returned to the facility with the feeding tube and [DEVICE]. There are many nutritional notes by the facilities Registered Dietitian (RD) starting on 04/03/19 read as follows: Resident triggering for Signiant weight loss of 15 pounds in three (3) months, Resident with a weight gain in one (1) month. Current weight 157.8 pounds. Resident was receiving enteral bolus via feeding tube after meals. if he consumes less than 50 % of meals. On 05/01/19 note reads as follows: Resident continues to trigger for weight loss. Down 21.7 pounds in 180 days and 7.1 pounds in 30 days. Current weight 150.7. Resident on a regular puree diet and one (1) can of Two Cal via feeding tube if he consumes less than 50% of meals. Registered Dietitian (RD) recommends double portions. On 05/14/19 note reads as follows: Resident continues to trigger for weight loss. Down 9.1 pounds in one (1) month. Current weight 148.7. feeding tube removed on 05/08/19 due to not being used. Nursing will continue to monitor weights and resident will receive double portions. On 05/22/19 note reads as follows: Resident continues to trigger for weight loss. Down 12.1 pounds in two (2) months and 5.6 pounds in one (1) month. Current weight 145.1 pounds. Staff recorded 51-75 % consumption of meals. Staff also report resident not eating well and has felt nauseous. On 06/12/19 note reads as follows: Resident continues to trigger for weight loss, however weight has been stable between 144-150 pounds for 30 days. Current weight 143 pounds. On 07/10/19 at 12:00 PM, observation of lunch Resident # 23, he is ordered double portions for meals. Observation of the lunch that was served the portion sizes appeared to be the same as the other puree diets. Which was one (1) rounded mound of mashed potatoes, one (1) rounded mound of cornbread, one mound of carrots, and chili with beans on the plate unable to determine the amount because it was at a runnier consistence. Resident #23 did not receive a meal as ordered. The physicians order dated 03/01/19, for a regular diet, puree texture, nectar consistency, double portions. Also, the printed-out meal tickets state on the bottom double portions. On 07/10/19 at 12:28 PM, Certified Dietary Manager (CDM), was asked to observe the portion size on the plate belonging to Resident #23. He was asked if he should have received two scoops of everything? He stated, yes, unless they used a larger scoop. We went back to the serving area and there was not a larger scoop being used. On 07/10/19 at 12:30 PM, Cook #71 was asked if he served Resident #23 double portions on his tray today for lunch? He stated, that he gave him double protein. When he was asked if he gave double scoops of the meal, he stated that gave the large scoop and when he was asked to show what size scoop he used, he then stated, that he put two (2) scoops of everything on his plate. KM # was asked if he saw two (2) scoops of anything on the plate he did not answer. On 07/10/19 at 1:06 PM, RD stated, that Resident # 23 is supposed to get two scoops using a regular size scoop not the large scoop. She said, that will re-educate the CDM and Cook #71 She was asked about the weight loss trending down and she replied that Resident #23 is such a good eater she feels like if he got double portions his weight would be more stable. She went on to say that if he was getting double portions his weight should have been stabilized. On 07/10/19 at 4:00 PM, RD entered the room to present a noted that she stated she had written earlier this morning at 12:48 PM, and that Resident #23 had had a Four (4) pound weight increase. Weight was stable between 143-147 for seven (7) days, Weights were decreased to monthly due to weight range stable for four weeks from 05/21/19 to 06/10/19. Diet is meeting estimated needs on regular portions-but double portions ordered do to excellent intake and continues to trigger for weight loss. During this time, it was pointed out to the RD that the note she is now saying she wrote this morning was actually created on 07/10/19 at 2:30 PM, and she was asked if she still thought a double portion size meal were in the best interest of the resident? She stated, that he probably did not need them. She was asked if she remembered that at 1:00 PM, today she stated, that she feels like if Resident #23 was getting his double portions his weight would stabilize? She did not answer. On 07/10/19 at 4:05 PM, the facility's DoN and Corporate RN #83 stated that a weekly weight meeting had been held on 07/05/19, after they had previously stated that the meeting for that week had been cancelled due to a holiday. They added that not all of the notes from the meeting on 07/05/19 had been entered in the medical records of the residents discussed. However, he was on the list to be discussed today. Corporate RN #83 proceeded to show his name on the list, but he was not listed. DoN agreed that the notebook that she had with her was not a part of the medical record. No further information was provided prior to the survey exit conference.",2020-09-01
320,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2019-07-10,761,D,0,1,L7T111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. Four (4) multi-dose medications located in medication carts were not dated when the medication was first accessed or opened. These were random opportunities for discovery made during the medication storage and labeling facility task. Resident identifiers: #59, #29, #65. Facility census: 72. Findings included: a) Resident #59 On [DATE] at 9:10 AM, inspection of the 'long hall' medication cart was performed. One (1) of 12 insulin pens in this medication cart did not have a date to indicate when the medication was first opened. This insulin pen was Humalog insulin for Resident #59. The label on the insulin pen indicated the medication was delivered from the pharmacy to the facility on [DATE]. Labeling multi-dose medications when first opened or accessed is important to determine the expiration date of the medication. Insulin pens have an expiration date determined by when the pen was used for the first time. Licensed Practical Nurse (LPN) #44 confirmed the Humalog insulin pen for Resident #59 was not dated when first opened or accessed. During an interview on [DATE] at 10:30 AM, the Director of Nursing stated facility policy was to date insulin pens when opened. However, she stated Resident #59's insulin pen could not be outdated or expired because it had been delivered from the pharmacy on [DATE]. The facility's policy entitled, Medication Administration-Preparation and General Guidelines - Vials and [MEDICATION NAME] of Injectable Medications stated, The date opened and the initials of the first person to use the vial are recorded on multidose vials. On [DATE] at 3:18 PM, the Administrator was informed of the above-described findings. No further information was provided through the completion of the survey. b) Resident #29 During an observation on [DATE] at 9:21 AM, of the medication cart being used by Registered Nurse (RN) #47, revealed that, the one (1) of the three (3) vials of a multi-use insulin (a medication used to control glucose levels for people who have diabetes) did not have a date on the vial to indicate when this medication was initially opened. [MEDICATION NAME] (name of the insulin) belonged to Resident # 29. It is a professional standard to label the vial with the date it was initially accessed, because after initial access the medication has the potential to loss potency and the effectiveness to treat the glucose levels for diabetic patients. Also a multi-use nasal spray ([MEDICATION NAME]) belonging to Resident #29 did not have a date on the bottle to indicate when it was initially opened. This was true for two (2) of two (2) nasal sprays in this medication cart. c) Resident #65 During an observation on [DATE] at 9:21 AM, of the medication cart being used by Registered Nurse (RN) #47, revealed that two (2) of two (2) nasal sprays [MEDICATION NAME] did not have a date on the bottle to indicate when this medication was initially used. This medication belonged to Resident #65. On [DATE] at 9:26 AM, Registered Nurse #47 was witness and verified there was not a date on the medication bottles to indicate the initial date it was used. During an interview on [DATE] at 11:39 AM, Director of Nursing was informed of findings. She had no comment. No further information was provided prior to the survey exit conference.",2020-09-01
321,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2019-07-10,842,D,0,1,L7T111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #222 and Resident #12's medical record was complete and accurate. For Resident #222 the Nursing Admission Data Collection tool was inaccurate in the area of dental status. Resident #12's quarterly pain evaluation was inaccurate. This was true for two (2) of 17 records reviewed during the long term care survey. Resident identifiers: #222 and #12. Facility census: 72. Findings included: a) Resident #222 A review of Resident #222's medical record at 9:00 a.m. on 07/09/19 found an Admission Data Collection assessment dated [DATE]. A review of this assessment found the following under section B. Oral Health/Dentition 1. Condition of Teeth/oral Cavity both [NAME] Natural Teeth Intact B. Edentulous were marked as being true for Resident #222. Edentulous is defined in the Resident Assessment Instrument manual as meaning no natural teeth. A review of Webster's dictionary found the word Edentulous means toothless. Interview with the Director of Nursing (DON) at 2:05 p.m. on 07/09/19 confirmed that both Edentulous and Natural Teeth intact were both marked as being true for this resident. No further information was provided prior to the survey exit conference. b) Resident #12 Resident #12 had a Quarterly Pain Evaluation on 07/09/19. The question At any time during the last 5 days, has the resident been on a scheduled pain management regimen? was answered as No. Review of Resident #12's medical records revealed an order written [REDACTED]. On 07/09/19 at 2:00 PM, the Director of Nursing (DoN) was informed Resident #12's Quarterly Pain Evaluation on 07/09/19 documented the resident was not on a scheduled pain management regimen although the resident was on [MEDICATION NAME] daily for pain. The DoN stated the nurse completing the pain evaluation may not have considered [MEDICATION NAME] as a pain medication because the medication has other uses. On 07/09/19 at 3:17 PM, the above-described findings were reported to the Administrator. No further information was provided prior to the survey exit conference.",2020-09-01
322,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2019-07-10,880,D,0,1,L7T111,"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 nurse failing to use a barrier during medication administration. This was a random opportunity for discovery during an observation of medication administration. Resident identifier: #55. Facility census 72. Findings included: a) Resident #55 During an observation on 07/09/19 at 9:01 AM, Registered Nurse (RN) #47 was administrate ring medications to Resident # 55. She entered the resident's room with a medication cup containing pills and an inhaler (used to treat asthma). RN #47 placed the Brevo inhaler placed inhaler on bedside table without using a barrier. On 07/09/19 at 9:12 AM, RN #47 was asked about not using a barrier when she placed the inhaler on the bedside table. She stated, that she just forgot, they have told her over and over to use a barrier. On 07/09/19 at 11:39 AM, Directior of Nursing (DoN) was informed of the observation of the barrier not being used during a medication administration. She had no comment. No further information was provided prior to the survey exit conference.",2020-09-01
345,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2017-03-10,225,D,0,1,7ZXP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, observation, record review, and staff interview, the facility failed to thoroughly investigate incidents that occurred with two residents (#47 and #119). Resident identifiers: #47 and #119. Facility census 132. Findings include: a) Resident #47 On 03/07/17 at 3:22 p.m., the most recent Minimum Data Set (MDS) assessment with an Assessment Reference Date of 01/15/17 for Resident #47 was reviewed. The MDS indicated the resident had [DIAGNOSES REDACTED]. At 3:28 p.m. the care plan was reviewed. An Immediate Needs care plan was completed on 02/14/17 for the left hand and left forearm that was purple and bruised. Interventions included: to monitor daily and observe for infection, inflammation, redness, and tenderness. Review of resident form, dated 02/14/17 at 4:00 p.m., had a statement from the resident, It happened this a.m. when they were changing my shirt. The form indicated there was a large ecchymotic (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising) area noted to left hand extending up the left forearm while up in a while up in motorized wheelchair. The injury was described as a large purple, ecchymotic area that start at top of left hand and extends up left forearm to elbow. The area measured 19 centimeters (cm) by 38 centimeters. The resident denied pain. The second page of the Resident Form was titled Incident Review and was blank. A nursing notes, dated 02/14/17 at 7:00 p.m., noted the resident was up in his motorized wheelchair with a large ecchymotic area to his left hand and left forearm measuring 19 cm by 38 cm, dark purple, denies pain. The nurse documented the resident states the bruise occurred when his shirt was being changed on the morning of 02/14/17. The medical power of attorney was present and notified and the physician notified. On 03/07/17 at 5:06 p.m., Resident #47 was interviewed. The resident stated the bruise on his left arm happened one morning when the staff were assisting him to get his shirt on. He stated the staff were holding his arm to get it into his shirt. The resident denied being abused and stated he bruises very easily. On 03/07/17 at 5:29 p.m., Registered Nurse (RN) #56 was interviewed. RN #56 stated she worked the day the bruise was found on the resident's left arm. The RN stated the resident reported to her it happened that morning when he was getting his shirt on. She completed a resident form, but did not report abuse, no further investigation on her part was done. RN #56 stated social services picks up the resident forms and follows up. On 03/08/17 at 10:36 a.m., Licensed Practical Nurse (LPN) #163 was interviewed. LPN #163 stated she recalled the incident and stated the resident told her it happened when the staff was helping him get dressed. LPN #163 stated the staff held his arm to help get it in the arm hole and then a bruise occurred. On 03/08/17 at 3:43 p.m. interviews were done with the Social Service Director (SSD) #14 and the Director of Nursing (DON) #105 regarding the incident. The DON stated the resident's incident report was completed by RN #56. The form was picked up by Licensed Social Worker (LSW) #78 and then returned to the DON. The second page of the investigation was not completed by LSW #78. DON #105 stated she interviewed RN #56 and ask her what happened. RN #56 told her the resident reported the bruise at 4:00 p.m. that day and told her it happened with dressing that morning, but the resident had been up in his chair and she was not sure of what happened. The DON verified she didn't do any follow up with the staff or the resident on the bruise. SSD #14 stated that she was going to re-open the case and complete the investigation because it was not done on 02/14/17 when the nurse completed the incident report On 03/08/17 at 4:11 p.m., RN #56 was re-interviewed. RN #56 stated the resident reported the bruise to her around 4:00 p.m. on 2/14/17. RN #56 stated the resident told her the bruise happened when the staff was helping him get dressed that morning. She stated he had been up in his scooter and had had another incident awhile back where he ran his scooter into the wall and got a bruise. She was not sure how he really got the bruise. She stated she did not question him further about how the bruise occurred. b) Resident #119 Resident #119 was admitted on [DATE] and readmitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 12/11/16 significant change Minimum Data Set (MDS) assessment, the resident had moderately impaired cognition with a brief interview for mental status (BIMS) score of 9 out of 15. Resident #119 required extensive assistance of two persons for toileting. The care plan, initiated 12/15/16, identified the resident is incontinent with impaired mobility putting her at risk for impaired skin integrity and further complications. Interventions included: provide assist with toileting per facility protocol and provide incontinence care as needed. Resident #143 (Resident 119's roommate) was interviewed on 03/06/17 at 11:09 a.m. She said staff fussed at her roommate for having to go to the bathroom too often. She said one girl did yell at her telling her she just went to the bathroom. Resident #143 could not recall who the staff was. She told social services about the incident. Resident #119 was interviewed on 03/06/17 at 3:47 p.m. She said one of the nurse aides had told her you just went to the bathroom. On 03/07/17 at 2:57 p.m., the resident was interviewed again. She said she had to go to the bathroom two to three times a night. The nurse aide came in and said oh, you have to go to the bathroom again. You just went 10 minutes ago. It made her feel bad at the time. According to the investigation report, dated 01/16/17: --Incident date: unknown --Incident was reported on 01/16/17 by resident who said the incident happened a couple of days ago. --Alleged perpetrator: Nurse Aide (NA) #31 --Name of victim: Resident #119 --Reported to APS (adult protective services): Yes --Name of complainant: Resident #119 According to the follow up report for this investigation, dated 01/21/17: --Alleged perpetrator: NA #31 --Substantiated: Yes --Upon investigation, residents/staff were interviewed. It was reported that NA #31 at times is in a hurry and she has an attitude when asked for assistance. No reports of physical/ mental abuse were noted. NA #31 was counseled and will be moved to working another shift with more supervision. (This report was faxed to the State nurse aide registry on 01/21/17) According to the staffing schedule in January, NA #31 worked the nights of 01/16/17, 01/18/17, 01/20/17, and 01/21/17. According to the investigation report, dated 01/16/17: --Incident: unknown --Alleged perpetrator: NA #211 --Name of victim: Resident #119 --Name of complainant: Resident #143 (roommate) According to the follow up report for this investigation, dated 01/21/17: --Alleged perpetrator: NA #211 --Substantiated: Yes --Upon investigation, interviews with residents and staff reported that NA #211 can have an attitude with residents and that she needs to be more sensitive with resident's requests for assistance with using the bathroom or with transfers. NA #211 to be counseled and moved to a different shift with more supervision. (This report was faxed to the State nurse aide registry on 01/21/17) According to the staffing schedule in January, NA #211 worked the nights of (MONTH) 01/17/17, 01/19/17, and 01/20/17. There were six resident interviews completed and documented for both investigations on 01/18/17. (Two days after the incident was reported). No staff interviews were documented. Social Services Employee (SSE) #78 was interviewed on 03/07/17 at 2:17 p.m. He said he interviewed six (6) residents on 01/18/17. He said he talked with three (3) staff and they did not say anything. APS was not assigned to investigate. The Nursing Home Administrator (NHA) #161 and SSE #78 were interviewed on 03/07/17 at 4:00 p.m. The NHA said when they received an allegation, they would ensure the resident was safe. They interviewed the residents and staff involved. They reported to APS, law enforcement and the nurse aide registry. She said they did not substantiate it upon investigation. She said, Sometimes they suspended the staff and sometimes they didn't. It depended on if physical abuse was involved. It depended on the seriousness. She said in this case, she couldn't suspend them. SSE #78 did not remember the dates he talked with staff. The record contained no evidence of interviews with staff. The NHA said they did a preliminary investigation and the resident was not fearful. They would have normally talked with the staff and let them know there was an allegation against them. SSE #78 did not ask about the specific event. The NHA said, the investigation could have been better. The Director of Nursing (DON) #105 was interviewed, on 03/07/17 at 5:09 p.m., and she said the two nurse aides were supervised during their shift after the allegation. The nurse was to go into the rooms along with the nurse aides. She said SSE #78 had talked with the nurse aides, but she did not know what he told them regarding the investigation. At 5:25 pm., the DON said she did not know if the incident was reported to the State nurse aide registry. She said there was nothing in the NA's personnel files regarding the investigation, allegation or reporting to the State nurse aide registry. She confirmed there was confusion regarding the investigation. The NA #211 was interviewed on 03/08/17 at 10:05 a.m. She said she never talked with SSE #78 in (MONTH) regarding any incident. The last time she had talked with SSE #78 was when she first started. She was unaware of any recent investigation. She said her coworker, NA #31 had received a call from SS #78. The NHA #161 was interviewed, on 03/08/17 at 10:15 a.m., and she said they were re-opening the investigation. The SSD #14 was interviewed on 03/08/17 at 11:00 a.m. She said she was off in (MONTH) and did not know much about this investigation. She state they re-opened this investigation as a result of surveyor intervention.",2020-09-01
346,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2017-03-10,371,F,0,1,7ZXP11,"Based on observations and staff interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service in five (5) of five (5) kitchens and one (1) in four (4) dining rooms. Specifically, the facility failed to ensure proper glove use; ensure proper sanitizer concentration in the sanitizer buckets; date and seal foods; ensure expired foods were disposed of; and utilize hairnets during meal service. This failed practice had the potential to affect all the residents receiving nutrition from five (5) out of five (5) kitchens in the nursing home. Facility census: 132. Findings include: a) Glove Use 1. Observations The sunny brook dining room service was observed on 03/06/17 at 12:12 p.m. Activity Staff #22 was observed with gloves on while assisting two residents. She grabbed her chair from underneath to help pull her chair forward. She was then observed touching a resident's sandwich with the same gloves. She then handed the resident the sandwich. At 12:25 pm., Activity Staff #22 was observed to have held a residents' hand with her left hand. She grabbed another resident's sandwich and handed it to her with her right hand. She proceeded to grab the underside of her chair again and pull herself forward. She picked up the sandwich and handed it to the resident with her right hand (the same hand as used on the underside of the chair). She grabbed the sandwich with left hand (the same gloved hand she used to hold another residents hand). She held the sandwich down and cut it up for the resident. She picked up the portion of the sandwich with both hands. (All of this was completed with the same gloves). 2. Staff Interview Activity Staff #22 was interviewed on 03/08/17 at 12:52 p.m. She said she had been through the feeding assistant program a few years ago. She had an in-service on glove use at least yearly. She said she had no excuse as to why she used the gloves improperly. Dietary Manager #37 was interviewed on 03/08/17 at 1:00 p.m. She said they in-serviced proper glove use last year. 3. Expectations According to the 2013 Food Code from the U.S Department of Health and Human Services, page 74, If used, single-use gloves shall be used for only one task such as working with ready-to-eat foods or with raw animal food, used for no other purpose, and discarded when damaged or soiled. 4. Facility Standards According to the glove use policy provided by DM #37, on 03/08/17 at 1:00 p.m., dated 01/2009, Change disposable gloves between tasks and not wear them continuously .Employees will not handle ready-to-eat and cooked foods without washing their hands and changing their gloves. b) Sanitizer Concentration 1. Observations Sunny Brook kitchen was observed on 03/06/17 at 8:50 a.m. The sanitizer bucket measured 2. Staff Interview The Dietary Employee #41 was interviewed on 03/06/17 at 8:50 a.m. She said they would either fill the red sanitizer bucket with either Comet, or Dawn and Bleach. The Dietary Employee #114, from the secure unit kitchen, was interviewed on 03/07/17 at 10:10 a.m. She said she used bleach and water or some other chemical for the sanitizer bucket. She used the sanitized water for the walls and countertops. She said she did not measure the concentration of the sanitizer. The DM #37 was interviewed on 03/08/17 at 7:05 a.m. She said they were supposed to use bleach for the red buckets and they were supposed to measure the concentration on the floors. She said the staff had been in-serviced this process. The DM #37 was interviewed on 03/08/17 at 1:00 p.m. She said they in-serviced the staff in (MONTH) regarding the sanitizer. She confirmed there was no specific place for bucket sanitizer documentation. 3. Facility Standards According to the Sanitation Solution Policy provided by the DM #37 on 03/08/17 at 1:00 p.m., dated 6/16, Sanitation solution buckets are to be kept in each kitchen filled with 2-quarts water and 1-1/2 teaspoon bleach to be changed after each meal. c) Dated and Sealed Foods 1. Observations The main kitchen was observed on 03/06/17 at 8:05 a.m. Twelve (12) small containers of ranch dressing were observed as undated. Four (4) containers of another salad dressing were observed as undated. The Sunny Brook kitchen was observed on 03/06/17 at 8:50 a.m. A small metal pan of egg salad, covered in aluminum foil, was observed as undated and unlabeled. The Enchanted Garden kitchen was observed on 03/06/17 at 9:15 a.m. A 28-ounce box of cream of rice (1/4 full) was observed as open to air, unsealed. The refrigerator for Resident #119 was observed on 03/06/17 at 3:28 p.m. A container of applesauce and a container of cottage cheese was observed, undated. The Secure Unit kitchen was observed on 03/07/17 at 10:10 a.m. with the following: --The freezer contained two (2) clear plastic bags of meat patties, undated and unlabeled. --The freezer contained two (2) Klondike bars were observed as open, unsealed. --A full box of cream of wheat was observed in dry storage, unsealed. 2. Staff Interview The Dietary Employee #41 was interviewed on 03/06/17 at 8:50 a.m. She said she did not know when the egg salad was put into the refrigerator. She said, I will throw it away. She said they might have forgotten to date the food item or they just placed clean foil on top. She confirmed there was no date on the egg salad. The DM #37 was interviewed on 03/08/17 at 1:00 p.m. She said the activity staff used the Klondike bars. Housekeeping was responsible for the resident's refrigerators. The salad dressings would have been the responsibility of the cooks. She said ultimately, dietary was responsible. 3. Expectations According to the 2013 Food Code from the U.S Department of Health and Human Services, page 92, Ready-to-eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment . and the day or date marked by the food establishment may not exceed a manufacturer's use-by date based on food safety. According to the 2013 Food Code from the U.S Department of Health and Human Services, page 68, Food shall be protected from cross contamination . d) Expired Foods 1. Observations The Enchanted Garden kitchen was observed, on 03/06/17 at 9:10 a.m., with the following: --A five-pound container was observed in dry storage with a best by date of 03/08/16. --Four 8-ounce cans of strawberry ensure plus dated (MONTH) 1, (YEAR). --The refrigerator for Resident #119 was observed on 03/06/17 at 3:28 p.m. A small 2% milk carton was observed with a sell by date of (MONTH) 17th. The secure unit kitchen was observed on 03/07/17 at 10:10 a.m. with the following: --A nonfat chocolate milk carton was observed with a sell by date of 02/27/17. 2. Expectations According to the 2013 Food Code from the U.S Department of Health and Human Services, page 92, The day or date marked by the food establishment may not exceed a manufacturers use-by-date if the manufacturer determined the use-by-date based on food safety. 3. Facility Standards According to the food safety policy provided by the DM #37 on 03/08/17 at 1:00 p.m., dated 2/2012 stated, Anything not labeled or dated must be discarded immediately. e) Hairnets 1. Observations The Sunny Brook kitchen service was observed on 03/06/17 at 12:07 p.m. The Activity Staff #22 was observed in the kitchen area during meal service. She was not wearing a hairnet. She was observed around the cooked chicken fingers, sitting on the stove. She had some ice cream in the microwave and waited for it to melt. This occurred in the middle of meal service with the steamtable behind her. The Garden Place kitchen was observed on 03/07/17 at 12:06 p.m. An unknown staff member was observed in the kitchen throughout the beginning of meal service. By 12:09 p.m., she was observed to have put on a hairnet. The Enchanted Garden kitchen was observed on 03/07/17 at 4:57 p.m. NA #61 was observed assisting in the kitchen during meal service without a hairnet. 2. Staff Interview The Activity Staff #22 was interviewed on 03/08/17 at 12:52 p.m. She said she was unaware of any policies related to hairnets in the kitchen. She said she didn't even think about the need to wear a hairnet. She was focused on getting the ice cream melted. The DM #37 was interviewed on 03/08/17 at 1:00 p.m. She said she was not sure if the other staff had been educated on the use of hairnets. She had not in-serviced them. 3. Expectations According to the 2013 Food Code from the U.S Department of Health and Human Services, page 51, 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 . 4. Facility Standards According to the dress code policy provided by the DM #37 on 03/08/17 at 1:00 p.m., undated, Hair nets must be worn at all times.",2020-09-01
347,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2018-04-26,641,D,0,1,J1N911,"Based on medical record review and staff interview, the facility failed to complete an accurate minimum data set (MDS) assessment for one (1) of forty-three (43) assessments reviewed. The MDS for Resident #41 did not accurately reflect the resident's status for end-of-life prognosis. Resident identifier: #41 Facility census: 134. Findings included: a) Resident #41 A review of the medical record, for Resident #41 on 04/23/18, revealed the quarterly MDS with assessment reference date (ARD) of 02/18/18 did not correctly record this resident having a life expectancy of less than six (6) months. A review of the certification narrative signed by the physician on 08/25/17, and re-certification on 02/21/18 had Resident #41 with a prognosis of six (6) months or less life expectancy. Resident #41 received hospice services since 08/25/17. In an interview, with the MDS Coordinator on 04/25/18 at 9:40 AM, the MDS Coordinator verified the quarterly MDS with the ARD of 02/18/18 did not include the prognosis of life expectancy of less than six (6) months for Resident #41.",2020-09-01
348,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2018-04-26,656,E,0,1,J1N911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record reviews and staff interviews, the facility failed to develop comprehensive person-centered care plans for three (3) of 43 care plans reviewed. Resident #41 in the area of enteral feeding and advance directives. In addition, Resident #77's care plan did not address enteral feeding. Resident #64's care plan did not address a pressure area. Resident identifiers: #41, #77, and #64. Facility census: 134. Findings included: a) Resident #41 A review of the medical record, for Resident #41 on 04/25/18, revealed the comprehensive care plan written on 11/27/17 did not address the tube feeding delivery system, formula, volume, rate, duration, caloric value, and hydration or specific flushing of the [DEVICE] ([DEVICE]) before/after medication administration and while the tube feeding was being infused. The medical record review revealed a physician's orders [REDACTED]./17. In an interview with Employee #147 registered nurse (RN) and unit charge nurse on 04/25/18 at 12:01 PM, verified the care plan did not include formula, delivery system, duration, caloric value, rate or water flushes for [DEVICE] feeding for Resident #41. Further review of the care plan revealed failure to develop a comprehensive person-centered care plan for Advance Directives for end-of-life wishes for Resident #41. An interview with the Director of Social Services, on 04/25/18 at 10:45 AM, verified the Advance Directives or end-of-life wishes were not addressed on the care plan for Resident #41. b) Resident #77 A review of the medical record, for Resident #77 on 04/25/18, revealed the care plan did not address the tube feeding delivery system, formula, volume, rate, duration, caloric value, and hydration or specific flushing of the [DEVICE] ([DEVICE]) before/after medication administration and while the tube feeding was being infused. The enteral feeding order was for: Advance Glucerna 1.2 by 10 milliliters (ml) every eight (8) hours to goal rate of 80 ml/20 cc flush; to run from 10:00 PM to 6 PM; flush with 15 cc of water before and after each medication administration; change tubing daily upon start of new bottle. percuaneous endoscopic gastronomy (peg). Start date for order 02/26/18. Interview with Registered Nurse/Unit Charge Nurse (RNUCN) #147, on 04/25/18 at 4:25 PM, verified the care plan did not include the formula, delivery system, duration, caloric value, rate or water flushes for [DEVICE] feeding for Resident #77. c) Resident #64 Resident #64 had [DIAGNOSES REDACTED]. Clinical record review revealed a care plan entitled immobile, totally incontinent and dependent on staff to meet resident all needs related to cognitive losses associated with advanced dementia. This puts her a risk further contractures and further skin breakdown. Interventions included: alternating pressure mattress, consult with dietitian, body checks and Braden assessment as ordered and gel foam cushion with coccyx cut when up. The care plan included no wound care orders and no weekly assessment of her wounds. A 6/9/18 physician order [REDACTED]. A 4/3/18 physician order [REDACTED]. During an interview, on 04/25/18 at 12:15 PM, MDS (Minimum Data Set) Coordinator #17 stated only she and the Director of Nursing developed and revised the care plans. MDS #17 stated Resident #64 had the Kennedy ulcers since her admission to the facility. MDS #17 stated the care plan should have included weekly assessments of the Kennedy ulcers and the wound treatments done to treat the ulcers. MDS #17 stated she would revise the care plan to include these interventions.",2020-09-01
349,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2018-04-26,684,D,0,1,J1N911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide treatment and care needed in accordance with professional standards of practice to meet the physical, mental and psychological needs for one (1) of forty three (43) residents reviewed related to pain medication. Resident identifier: #121. Facility census: 134. Findings included: a) Resident #121 Review of the physician orders [REDACTED]. Instructions include to give if the residents pain level is four or greater on a pain scale of one (1) - ten (10). The (MONTH) (YEAR) Medication Administration Record [REDACTED]. The (MONTH) (YEAR) monthly MAR indicated [REDACTED]. Review of nursing notes also found no evidence of obtaining the level of pain. On 04/25/18 at 8:46 AM, Registered nurse #147 agreed the pain levels had not been obtained in accordance with the physician order. Review of nursing notes also found no evidence of obtaining the level of pain. On 04/25/18 at 8:46 AM, Registered Nurse #147 agreed pain levels had not been obtained in accordance with the physician order.",2020-09-01
350,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2018-04-26,697,D,0,1,J1N911,"**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 43 residents received treatment and care in accordance with professional standards related to the recognition and management of pain. Resident identifier: #121. Facility census: 134. a) Resident #121 Review of Resident #121's care plan revealed a start date of 02/12/18 with a problem of pain monitoring and management due to a healing right [MEDICAL CONDITION] and arthritis. On 04/24/18 at 9:16 AM Resident #121 explained she had pain most of the time. Medical record review revealed a physician's orders [REDACTED]. Instructions included to give the medication if the residents pain level was four (4) or greater on a pain scale of one (1) - ten (10). The (MONTH) (YEAR) Medication Administration Record [REDACTED]. The (MONTH) (YEAR) MAR indicated [REDACTED]. Review of nursing notes also found no evidence of obtaining the level of pain. On 04/25/18 at 8:46 AM, Registered nurse #147 agreed pain levels were not obtained in accordance with the physician order.",2020-09-01
351,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2018-04-26,741,E,0,1,J1N911,"Based on observations and staff interviews, the facility failed to provide sufficient staff with basic competencies and skills sets to meet the behavioral health needs of residents to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Multiple observations identified residents with cognitive impairment and/or dementia and dependent on staff for all aspects of care sitting in the dining area with minimal staff interaction and/or activities. Staff failed to respond to residents' repeated cries for help and failed to offer non-pharmacological interventions in response to these cries. This had the potential to affect more than an isolated number of residents. Resident identifiers: #118, #72, #2, and #88. Facility census: 134. Findings included: An observation of the Enchanted Garden Dining room on 04/23/18, found staff assisting residents to the dining room at 11:30 AM. No drinks, activities or interactions were provided while residents waited 45 minutes or more for lunch to be served. In addition, staff failed to respond to a male resident's cry for help or to Resident #88's repeated statement of hunger. Observations of the Enchanted Garden Dining Room on 04/24/18, again found staff placing residents in the dining area at 11:30 AM. Resident #118 was observed repeatedly yelling help me. The unit secretary responded to his cries ten minutes later by positioning his wheel chair up to the table and stating lunch will be here soon. Resident #118 moved his wheel chair away from the table and again repeatedly yelled out help me. Staff failed to further address Resident #118's cries. Resident #2 was observed sitting at the end of a table without staff interaction, activity or drink. At 12:08 PM, Resident #88, sitting at the same table as Resident #2, began repeatedly yelling I'm hungry. An activity assistant was observed in the dining area prior to the meal service, communicating with a few residents at two (2) other tables. She failed to respond to the cries of Residents #118 or #88. Aside from the television in the corner playing music, no activities or drinks were provided to these residents prior to their lunch. During an interview, on 04/24/18 at 12:20 PM, the unit secretary/hospitality aide #94, acknowledged staff just get used to the residents cries and does noto respond to them like they should. During an interview, on 04/24/18 at 12:25 PM, the Unit Manager/ Registered Nurse (RN) #69, reported the hospitality aide could be offering drinks to the residents while they wait for their meals. RN #69 agreed some type of activity should be provided to the residents while they wait for their trays and stated it may keep the residents who are yelling, calmer. On 4/25/18 at 9:00 AM, Resident #72 was sitting in the Enchanted Garden dining are near the television repeatedly yelling out help. After repositioning her into a recliner, staff ignored her continued cries for help. On 04/25/18 at 10:20 AM, the Activity Assistant gathered several residents around the table, including Residents #72, and #2. Residents were offered a drink, and invited to participate in the conversation. All the residents in the dining area were calm and quiet. No one yelled out, and the residents remained quiet while waiting for their lunch. During an interview on 04/26/18 at 8:22 AM, Licensed Practical Nurse (LPN) #19, acknowledged the added staff to resident interaction activity with drinks, the morning of 04/25/18, really made a difference. All the residents were calmer and Resident #72 did not yell out for help the entire day.",2020-09-01
352,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2018-04-26,756,C,0,1,J1N911,"Based on policy review and staff interview, the facility failed to develop and maintain policies and procedures for the monthly drug regimen review that included but were not limited to, time frames for the different steps in the monthly medication regimen review process. This practice had the potential to affect all residents. Facility census: 134. Findings included: The facility policy titled Monthly Regimen Review stated under section seven (7): Timelines and responsibilities for Medication Regimen Review (MRR): --The consultant pharmacist shall schedule at least one monthly visit to the facility, and shall allow sufficient time to complete all required activities. --The pharmacist shall communicate any recommendations and identified irregularities via written communication within 10 working days of the review. --If the pharmacist should identify an irregularity that requires urgent action to protect a resident, the DON (Director of Nursing) or designee is informed verbally. --For residents experiencing a change in condition and the nurse deems a MRR is necessary outside the routine visit, the facility will notify the pharmacy provider. --Facility shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. The policy did not include time frames identified for physician notification following routine or urgent requests and no time frames for physician responses to pharmacy reviews. The Director of Nursing (DON) reviewed the current policy during an interview on 04/25/18, and confirmed the policy lacked specific time frames for the MRR review process, including times for physician notification and physician responses to monthly reviews and urgent requests.",2020-09-01
353,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2018-04-26,812,E,0,1,J1N911,"Based on observation and staff interview, the facility failed to prepare and serve food in a safe and sanitary manner. Cold food was not stored at an acceptable level, and food was served from a beside table in disrepair. Facility census: 134. Findings included: a) On 04/25/18 at 11:40 AM food temperatures were obtained by Dietary Aide, (DA) #76. Sliced turkey, to serve with a salad, was removed from the cooler with temperature of 43 degrees Farenheit. Dietary aid #76 explained the Turkey had been in the cooler for over two (2) hours and should be cooled to an acceptable level. The turkey was then placed in an insulated food transport container (with ice) and transported to the third floor dining room. The insulated food cart was transported to the old third floor dining area by DA #54. At 12:15 PM on 04/5/18 DA #54 obtained the temperature of the turkey which was 50 degrees Farenheit. The turkey was in a container sitting beside the cooling table. Nursing aid #54 explained the container would not remain upright in the cooling table. She then moved the container to the counter top. b) Enchanted Garden Kitchen On 04/24/18 at 12:29 PM, an observation of the Enchanted Garden kitchen revealed a bedside table in disrepair, with chipped edges on all four sides. Staff was observed utilizing this table during meal service. During an interview immediately following this observation, DA #87 acknowledged she used the table to hold the meal trays during meal service. The facility Administrator reported the table had been replaced, during the exit conference on 04/26/18.",2020-09-01
354,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2018-04-26,842,D,0,1,J1N911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews and staff interview the facility failed to complete and maintain accurate medical records for two (2) of two (2) residents whose medical records were reviewed for tube feeding during the survey process. Resident #41 and #77 had enteral feeding orders that did not include caloric values. Resident identifiers: #41 and #77. Facility census: 134. Findings included: a) Resident #41 A review of the medical record for Resident #41 on 04/25/18 revealed the enteral feeding order did not include the caloric value. The medical record revealed an enteral feeding order for the following: [MEDICATION NAME] 1.2 tube feeding via [DEVICE] ([DEVICE]) 1100 cubic centimeters (cc) total to run at 1100 cc/hour on at 10:00 PM off at 8:00 AM, nightly with 30 cc/hour water to flush to run continuously; flush with 15 cc of water after each medication; change tubing daily upon start of new bottle, start date for order 11/28/17. In an interview with Registered Nurse/Unit Charge Nurse (RNUCN) #147 on 04/25/18 at 12:01 PM, RNUCN #147 verified the enteral feeding order did not include the caloric value for Resident #41. b) Resident #77 A review of the medical record for Resident #77 on 04/25/18 revealed the enteral feeding order did not include the caloric value. The medical record revealed an Enteral Feeding order for the followng: Advance Glucerna 1.2 by 10 milliliters (ml) every eight (8) hours to goal rate of 80 ml/20 cc flush; to run from 10:00 PM to 6 PM; flush with 15 cc of water before and after each medication administration; change tubing daily upon start of new bottle. Percuaneous endoscopic gastronomy (peg). Start date for order 02/26/18. During an interview with RNUCN #147, on 04/25/18 at 4:25 PM, RNUCN #147 verified the enteral feeding order for Resident #77 did not reflect the caloric value.",2020-09-01
355,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2018-04-26,881,F,0,1,J1N911,"Based on staff interview and policy review, the facility failed to develop an antibiotic stewardship program that promoted the appropriate use of antibiotics. Actions were not implemented to improve antibiotic use and reduce adverse events associated with antibiotics. Antibiotic use protocols, and assessment tools were not utilized prior to the prescribing and administration of antibiotics. This practice had the potential to affect all residents residing in the facility. Facility census: 134. Findings included: a) Staff interviews During an interview, on 04/24/18 at 3:00 PM, the Infection-Control Nurse (ICN) #93 reported she listed all antibiotics administered and then determined if they met the McGeer's guidelines (an Infection surveillance checklist) after the antibiotics have been initiated. Licensed Practical Nurse (LPN) #13 was interviewed on 04/24/18 at 3:30 PM. She acknowledged she only used the McGeer's criteria when evaluating a resident for urinary tract infections prior to contacting the physician. LPN #139 reported there was no reference form or check off list related to McGeers for the nurses to utilize when they evaluated residents for other infections such as skin, respiratory or gastrointestinal. LPN #42 reported she was unaware of the term antibiotic stewardship or the use of any form or references such as the McGeer's criteria to utilize when evaluating a resident prior to starting antibiotics during an interview on 04/24/18 at 3:35 PM. On 04/25/18 at 3:00 PM, LPN #119 confirmed there was no established protocol for staff to follow or utilize when evaluating a resident for infection/illness prior to the administration of antibiotics. The facility policy titled (Name of Facility) Antibiotic Stewardship program, stated under the definition: Antibiotic (ABT) stewardship is a set of commitments and actions designed to make sure residents receive the right dose, of the right ABT, for the right amount of time and only when truly necessary. *The policy lacked any information related to assessment tools/references for nurses or physicians to utilize while evaluating a resident and prior to the initiation of an antibiotic.",2020-09-01
356,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2018-04-26,883,D,0,1,J1N911,"Based on record review, staff interview and policy review, the facility failed to ensure a resident and/or the resident's representative has the opportunity to refuse the influenza vaccine prior to annual administration. Resident #62 received the influenza vaccine during the (YEAR) flu season without a current signed consent. This was found for one (1) of five (5) residents reviewed. Resident identifier: #62. Facility census: 134. Findings included: a) Resident #62 Review of Resident #62's medical record, on 04/24/18, revealed she received the influenza vaccine on 10/04/2017. The influenza vaccination consent form was signed by Resident #62's representative on 07/23/15. Registered Nurse (RN) #69 / Unit Manager reviewed Resident #62's medical record during an interview on 04/24/18 at 11:15 AM, and confirmed the influenza consent form was dated (YEAR) and was signed by her late husband. RN #69 reported Resident #62's son is now responsible for signing consents. The facility Influenza Vaccine policy states under section 5. Individuals receiving the vaccine, or their legal representative, will be required to sign a consent form prior to the administration of the vaccine .",2020-09-01
358,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,550,D,0,1,S31911,"Based on observation, staff interview and policy review, the facility failed to ensure a resident received care in a manner that promoted dignity for one (1) of thirty (30) sampled residents. The facility posted signs with care needs described in plain view and failed to knock prior to entering the resident's room. Resident identifier: Resident # 107 Census: 134 Findings included: An observation on 06/24/19, at 11:24 AM, revealed a sign was posted above Resident #107's bed noting Do not use Chux ( a disposable underpad.) The sign was in plain view of anyone passing by. An additional observation on 06/25/19, at 08:22 AM, revealed HK#102 entered the room of Resident #107 carrying linen, without knocking or announcing herself. An interview on 06/25/19, at 11:16 AM, with LSW#23, revealed that information about dignity is gone over with staff during inservices and staff have been instructed to knock prior to entering the room. It was further stated no signs should be put up for instruction of care. On 06/25/19 , at 12:14 PM, a review of the facility's resident rights policy dated, 02/2018, under section 4.c., showed residents should have personal and medical information protected and not displayed openly for others to see.",2020-09-01
359,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,580,D,0,1,S31911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to contact a resident's physician concerning an order not being implemented. The physician was not contacted when a resident's family refused a decrease in the dosage of a medication stemming from a gradual dose reduction order. This practice affected one (1) of thirty (30) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifier: #12. Facility census: 134. Findings included: a) Resident #12 A review of the Resident's medical record, on 06/25/19 at 2:00 PM, revealed a Physician Recommendation Form with the dose reduction order [MEDICATION NAME] 10 milligrams daily decreased to [MEDICATION NAME] 5 milligrams daily dated 04/14/19. Licensed Practical Nurse (LPN) #191 wrote the note Family refused beside the order on 04/16/19. A review of the Nurses Notes, on 06/25/19 at 2:15 PM, revealed a note written by LPN #191 daughter refused pharmacy recommendations dated 04/16/19. Further review of the medical record revealed the reduction order written by the physician on 04/14/19 for [MEDICATION NAME] was never implemented and the physician was not contacted. An interview with the Alzheimer Unit Nurse Manager (AU-UM), on 06/25/19 at 2:30 PM, revealed there was no documentation that the physician was notified concerning the [MEDICATION NAME] order not being implemented. The AU-UM stated the order should have been implemented when the physician wrote the order on 04/14/19 and should have been contacted immediately once the family refused.",2020-09-01
360,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,583,E,0,1,S31911,"Based on staff interview and observation, the facility failed to ensure privacy and confidentiality of resident's personal and medical records. Pharmacy labels were left unattended on top of the medication cart when not in use. The labels contained personal identifiers including the resident's names, medications, and physicians. This was a random observation. Resident identifier: #47 and #386. Facility census: 134. Findings included: a) Observation An observation of a medication cart on the second floor, on 06/26/19 at 6:55 AM, revealed five (5) pharmacy labels for Resident #47 and Resident #386 were left on top of the medication cart while unattended. The pharmacy labels were visible for anyone walking past to see. The labels contained the following information concerning the Residents: --Resident's name --Medication --Physician b) Interview An interview with Registered Nurse (RN) #171, on 06/26/19 at 7:00 AM, revealed the pharmacy labels should have not been left on the medication cart while she was giving out medications. The RN stated she was getting ready to shred the labels.",2020-09-01
361,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,584,E,0,1,S31911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure a safe, clean, and comfortable environment for residents. Resident rooms had stained ceiling tiles, burned out light bulbs, scraped walls and doors, and a damaged footboard on a bed. This practice affected six (6) of seventy (70) rooms observed during the Long Term Care Survey Process (LTCSP). Room identifiers: #201, #202, #219, #221, #305, and #311. Facility census: 134. Findings included: a) Observations The following observations were made during the LTCSP on 06/24/19, 06/25/19, and 06/26/19: --room [ROOM NUMBER] - The bathroom ceiling had a missing tile. The bathroom ceiling tiles were stained. --room [ROOM NUMBER] - The bathroom light was not working. --room [ROOM NUMBER] - The ceiling tiles were stained above the bed. --room [ROOM NUMBER] - Bed A-The footboard was scratched. --room [ROOM NUMBER] - The wall was scraped on the left of the main door. The wall beside the refrigerator had a hole in it. --room [ROOM NUMBER] - The inside of the bathroom door was scraped. b) Interview An interview with the Administrator, on 06/26/19 at 7:50 AM, revealed monthly room rounds are conducted by the maintenance/housekeeping supervisors. The Administrator stated all other staff are to observe the rooms daily and report any environmental issues they see. The Administrator stated all of the issues found during the survey would be fixed immediately.",2020-09-01
362,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,609,D,0,1,S31911,"Based on record review, resident interview and staff interview, the facility failed to report an allegation of verbal abuse to the appropriate and required state agencies. This was a random finding while investigating an allegation of missing items. This failed practice had the potential to affect a limited number of residents. Resident identifier: #8. Facility census: 134. Findings included: a) While conduting interviews with residents on 06/24/19 during the initial tour revealed Resident #8 reported she had missing property. The surveyor asked the staff for any information regarding their actions to locate the missing items. The staff presented the surveyor with a concern report dated 01/23/19 which in the problem section stated the resident had reported the staff had yelled at her, been verbally abusive. In the response section it was addressing a missing item. The abuse of staff yelling at her had not been reported to the appropriate and required state agencies. Social worker #213, on 06/26/19 at 08:49 AM state there was no further evidence to show the staff had reported the alleged verbal abuse to the appropriate and required state agencies.",2020-09-01
363,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,610,D,0,1,S31911,"Based on record review, resident interview and staff interview, the facility failed to an allegation of verbal abuse. This was a random finding while investigating an allegation of missing items. This failed practice had the potential to affect a limited number of residents. Resident identifier: #8. Facility census: 134. Findings included: a) While conduting interviews with residents on 06/24/19 during the initial tour revealed Resident #8 reported she had missing property. The surveyor asked the staff for any information regarding their actions to locate the missing items. The staff presented the surveyor with a concern report dated 01/23/19 which in the problem section stated the resident had reported the staff had yelled at her, been verbally abusive. In the response section it was addressing a missing item. The abuse of staff yelling at her had not been investigated. Social worker #213, on 06/26/19 at 08:49 AM state there was no further evidence to show the staff had completed a thorough investigation of the alleged verbal abuse.",2020-09-01
364,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,656,D,0,1,S31911,"Based on observation, record review and staff interview, the facility failed to implement the care plan for bilateral padded side rails on a resident's bed. The facility failed to ensure that the side rails were covered by padding as directed on the care plan. This had the potential to affect one (1) of 30 residents. Resident identifier: #64. Facility census: 134. Findings included: a) Resident #64 An observation, on 06/24/19 at 11:31 AM, revealed the padding on the side rail of Resident #64's bed was missing and exposed the side rail on the right side of the bed. A record review of the care plan, on 06/24/19, revealed an intervention Padded siderails that is up at night and down during the day. An interview with Registered Nurse (RN) #172, on 06/24/19 at 1:13 PM, confirmed the padding should have covered the entire bed side rail and stated, I will call maintenance to come fix it immediately.",2020-09-01
365,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,657,D,0,1,S31911,"Based on medical record review and staff interview, the facility failed to revise a Care Plan for a resident that was utilizing side rails. The Resident was ordered 1/2 side rails and the care plan directed to use 1/4 side rails. This practice affected one (1) of thirty (30) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifier: #61. Facility census: 134. Findings included: a) Resident #61 A review of the Resident's physician orders, on 06/25/19 at 9:45 AM, revealed the order Bilateral 1/2 side rails when in bed for turning and positioning with a date of 09/04/18. A review of the Resident's Care Plan, on 06/25/19 at 9:55 AM, revealed the problem Resident requires staff assist for daily care due to impaired mobility with the intervention Bilateral 1/4 side rails as ordered. The Care Plan was dated 09/04/18. An interview with Registered Nurse-Unit Manager (RN-UM) #72, on 06/25/19 at 10:15 AM, revealed the Resident's Care Plan was incorrect and needed to say 1/2 side rails as ordered. The RN-UM stated he would fix the issue.",2020-09-01
366,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,684,E,0,1,S31911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and policy review, the facility failed to provide care and treatment in accordance with professional standards of practice and the comprehensive person centered care plan for seven (7) of thirty (30) sampled residents. The facility failed to obtain clarification for non-specific oxygen orders for four (4) residents. The facility failed to follow physician's orders for padded side rails for one (1) resident. The facility failed to obtain an order for [REDACTED]. Resident identifiers: #14, #107, #122, #92, #64, #57 and #12. Facility census: 134 Findings included: a) Resident #14 (R#14) A medical record review for R#14 on 06/24/19, at 12:03 PM , showed a doctor's order for oxygen to be administered by nasal annual to keep saturation levels above 92%. Initiate two (2) liters per minute but do not exceed four (4) liters per minute. Review of the policy and procedure on 06/25/19 at 11:44 AM, for oxygen administration , dated, 02/2017, noted the nurse shall verify physician's orders for rate of flow and route of administration. An interview on 06/25/19, at 02:02 PM, with RN#230, verified the oxygen orders for R#14 did contain a range and were non specific as to the rate to be used to treat the problem identified. RN#230 stated further, the facility will have to change the way orders are written. b) Resident #107 (R#107) A medical record review for R#107 on 06/25/19 at 08:21 AM, showed a physician's order to titrate oxygen via nasal cannula to maintain saturation levels greater than 90 percent. Review of the policy and procedure on 06/25/19 at 11:44 AM, for oxygen administration , dated, 02/2017, noted the nurse shall verify physician's orders for rate of flow and route of administration. An interview on 06/25/19, at 02:02 PM, with RN#230, verified the oxygen orders for R#107 did contain a range and were non specific as to the rate to be used to treat the problem identified. RN#230 further stated, the facility will have to change the way orders are written. c) Resident #122 (R#122) During a medical record review for R#122 on 06/25/19, revealed an order for [REDACTED]. This order did not ensure oxygen orders were clear and specific as to liters per minute LPM). In an interview with E226, Registered Nurse (RN) on 06/25/19 at 2:16 PM verified the oxygen orders for R122 were not clear and specific as to liters per minute (LPM). d) Resident #92 (R#92) During the initial tour of the facility on 06/24/19 at 11:37 R#92's oxygen delivery could not be observed as to what the setting was. Registered nurse (RN) #230 agreed the setting was set at six (6) liters per minute and reset the oxygen delivery to two (2) liters per minute. The current physician order with a start date of 10/27/17 is to titrate oxygen delivered by nasal cannula to maintain saturation greater than ninety (90) percent due to shortness of breath. On 06/25/19 at 2:15 PM RN #230 agreed the order does not clearly specify parameters related to setting the oxygen delivery level. e) Resident #12 A review of the Resident's medical record, on 06/25/19 at 2:00 PM, revealed a Physician Recommendation Form with the dose reduction order [MEDICATION NAME] 10 milligrams daily decreased to [MEDICATION NAME] 5 milligrams daily dated 04/14/19. Licensed Practical Nurse (LPN) #191 wrote the note Family refused beside the order on 04/16/19. A review of the Nurses Notes, on 06/25/19 at 2:15 PM, revealed a note written by LPN #191 daughter refused pharmacy recommendations dated 04/16/19. Further review of the medical record revealed the reduction order written by the physician on 04/14/19 for [MEDICATION NAME] was never implemented and the physician was not contacted. An interview with the Alzheimer Unit-Nurse Manager (AU-UM), on 06/25/19 at 2:30 PM, revealed the reduction order for [MEDICATION NAME] from (MONTH) 2019 was never implemented. The AU-UM stated there was no documentation that the physician was notified concerning the [MEDICATION NAME] order not being implemented. The UM stated the order should have been implemented when the physician wrote the order on 04/14/19 and should have been contacted immediately once the family refused. f) Resident #64 (R#64) An observation, on 06/24/19 at 11:31 AM, revealed the padding on the side rail of R#64's bed was missing and exposed the side rail on the right side of the bed. A record review of the care plan, on 06/24/19, revealed an intervention Padded siderails that is up at night and down during the day. A record review of the physician orders dated for 02/11/19, on 06/24/19, revealed, Regular bed against wall with bilateral padded side rails; side rails down during the day and up and night due to [MEDICAL CONDITION]. An interview with Registered Nurse (RN) #172, on 06/24/19 at 1:13 PM, confirmed the padding should have covered the entire bed side rail and stated, I will call maintenance to come fix it immediately. g) Resident #57 A record review of the Care Plan, on 06/25/19, revealed Problem:[NAME]dmitted to Valley Hospice D/T_[DIAGNOSES REDACTED]and is at risk for end of life complications such as but not limited to: ADL's, Falls, Contractures, Dehydration, Incontinence, Pressure Ulcers, Pain and Constipation and side effects of drugs. Valley Hospice Care started on 04/25/19. Additional record review of the Minimum Data Set (MDS), on 06/25/19, revealed Hospice was marked yes in section O of the MDS Assessment. A record review of the Physician Orders, on 06/25/19, revealed no Physician order for [REDACTED].>An interview with Registered Nurse (RN) #172, on 06/25/19 at 10:00 AM, revealed there was no physician order for [REDACTED].",2020-09-01
367,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,689,E,0,1,S31911,"**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 it had control. A medication room door was propped open and unattended, a bathroom accessible to anyone did not have a safety pull string, and a resident's bed rails were not padded as ordered. These practices had the potential to affect more than a limited number of residents. Resident identifier: #64. Facility census: 134. Findings included: a) 2nd Floor Medication Room An observation of the 2nd Floor, on 06/25/19 at 9:55 AM, revealed the Medication Room door was propped open. There were no nurses within site of the door at the time of the observation. The room contained multiple medications as well as wound care supplies for the 2nd Floor. An interview with Registered Nurse (RN) #219, on 06/25/19 at 10:00 AM, revealed she knew the door should never be propped open. The RN stated that stock medications, emergency medications, medications being sent back to the pharmacy, and wound care supplies were kept in the Medication Room. The RN closed the door immediately. b) 2nd Floor Staff Bathroom An observation of the 2nd Floor, on 06/24/19 at 11:00 AM, revealed a bathroom with the sign staff only along the hallway with the door propped open. The bathroom was accessible to anyone. The room did not have a safety pull string for emergencies. An interview with RN #219, on 06/24/19 at 11:05 AM, revealed the door to the staff bathroom is usually shut and locked. The RN verified the bathroom did not have an emergency pull string. The RN stated she would keep the door shut. c) Resident #64 An observation, on 06/24/19 at 11:31 AM, revealed the padding on the side rail of Resident #64's bed was missing and exposed the side rail on the right side of the bed. A record review of the care plan, on 06/24/19, revealed an intervention Padded siderails that is up at night and down during the day. A record review of the physician orders [REDACTED]. An interview with Registered Nurse (RN) #172, on 06/24/19 at 1:13 PM, confirmed the padding should have covered the entire bed side rail and stated, I will call maintenance to come fix it immediately.",2020-09-01
368,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,695,E,0,1,S31911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview and policy and procedure review, the facility failed to deliver respiratory care services consistent with professional standards of practice. Oxygen therapy orders were not specific for four (4) residents reviewed. Signs were not posted on doors for two (2) residents with orders for oxygen therapy. These practices affected four (4) of six (6) residents reviewed for respiratory care. Resident identifiers: #14, #107, #122, and #92 Facility census: 134 Findings included: a) Resident #14 (R#14) A medical record review on 06/24/19, at 12:03 PM , showed a doctor's order for oxygen to be administered by nasal annual to keep saturation levels above 92%. Initiate two (2) liters per minute but do not exceed four (4) liters per minute. On 06/25/19, at 09:49 AM, an observation revealed there was no oxygen sign on R#14's door. This observation was verified by RN#253 at this time. Review of the policy and procedure on 06/25/19 at 11:44 AM, for oxygen administration , dated, 02/2017, noted the nurse shall verify physician's orders [REDACTED]. An interview on 06/25/19, at 02:02 PM, with RN#230, verified the oxygen orders for R#14 did contain a range and were non specific as to the rate to be used to treat the problem identified. RN#230 stated further, the facility will have to change the way orders are written. Additionally, RN#230 verified there was no oxygen in use sign on the door and should have been. b) Resident #107 (R#107) A medical record review on 06/25/19 at 08:21 AM, showed a physician's orders [REDACTED]. An observation on 06/25/19, at 09:40 AM revealed R#107 had no oxygen warning sign on the door. This observation was confirmed through interview with RN#253 at this time. Review of the policy and procedure on 06/25/19 at 11:44 AM, for oxygen administration , dated, 02/2017, noted the nurse shall verify physician's orders [REDACTED]. An interview on 06/25/19, at 02:02 PM, with RN#230, verified the oxygen orders for R#107 did contain a range and were non specific as to the rate to be used to treat the problem identified. RN#230 further stated, the facility will have to change the way orders are written. Additionally, RN#230 verified there was no oxygen in use sign on the door and should have been. c) R122 During a medical record review for R122 on 06/25/19, revealed an order for [REDACTED]. This order did not ensure oxygen orders were clear and specific as to liters per minute LPM) also the flow rate was non-specific in providing a range for treatment. In an interview with E226, Registered Nurse (RN) on 06/25/19 at 2:16 PM verified the oxygen orders for R122 were not clear and specific as to liters per minute (LPM), also agreed the flow rate was non-specific in providing a range for treatment. d) Resident #92 During the initial tour of the facility on 06/24/19 at 11:37 Resident #92's oxygen delivery could not be observed as to what the setting was. Registered nurse (RN) #230 agreed the setting was set at six (6) liters per minute and reset the oxygen delivery to two (2) liters per minute. The current physician order [REDACTED]. On 06/25/19 at 2:15 PM RN #230 agreed the order does not clearly specify parameters related to setting the oxygen delivery level.",2020-09-01
369,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,730,F,0,1,S31911,"Based on personnel record review and staff interview, the facility failed to complete a yearly performance review for five (5) of five (5) staff personnel records reviewed. Staff identifiers: #2, #31, #26, #17, and #85. Facility census: 134. Review of personnel files for five nurse aides (#2, #31, #26, #17 and #85) employed by the facility greater than one year, found no evidence the facility completed yearly work performance evaluation as required by medicare and medicaid nursing home regulations. On 06/25/19 at 9:15 AM the facility Assistant Administrator, explained the facility does not complete yearly performance reviews.",2020-09-01
370,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,758,D,0,1,S31911,"**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's drug regimen was free from an unnecessary [MEDICAL CONDITION] drug. an order for [REDACTED]. Resident identifier: #12. Facility census: 134. Findings included: a) Resident #12 A review of the Resident's medical record, on 06/25/19 at 2:00 PM, revealed a Physician Recommendation Form with the dose reduction order [MEDICATION NAME] 10 milligrams daily decreased to [MEDICATION NAME] 5 milligrams daily dated 04/14/19. Licensed Practical Nurse (LPN) #191 wrote the note Family refused beside the order on 04/16/19. A review of the Nurses Notes, on 06/25/19 at 2:15 PM, revealed a note written by LPN #191 daughter refused pharmacy recommendations dated 04/16/19. Further review of the medical record revealed the reduction order written by the physician on 04/14/19 for [MEDICATION NAME] was never implemented and the physician was not contacted. An interview with the Alzheimer Unit-Nurse Manager (AU-UM), on 06/25/19 at 2:30 PM, revealed the reduction order for [MEDICATION NAME] from (MONTH) 2019 was never implemented. The AU-UM stated there was no documentation that the physician was notified concerning the [MEDICATION NAME] order not being implemented. The UM stated the order should have been implemented when the physician wrote the order on 04/14/19 and should have been contacted immediately once the family refused.",2020-09-01
371,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,761,E,0,1,S31911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff 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. The 2nd Floor Medication Room door was propped open and medications were unlabeled and undated as to when they were first used. These practices had the potential to affect more than a limited number of residents. Facility census: 134. Findings included: a) 2nd Floor Medication Room An observation of the 2nd Floor, on 06/25/19 at 9:55 AM, revealed the Medication Room door was propped open. There were no nurses within site of the door at the time of the observation. The room contained multiple medications as well as wound care supplies for the 2nd Floor. An interview with Registered Nurse (RN) #219, on 06/25/19 at 10:00 AM, revealed she knew the door should never be propped open. The RN stated that stock medications, emergency medications, medications being sent back to the pharmacy, and wound care supplies were kept in the Medication Room. The RN closed the door immediately. b) Undated and unlabeled medications An observation of the 2nd Floor Medication Room, on 06/25/19 at 11:30 AM, revealed the following medications were opened and not dated or labeled: -[MEDICATION NAME] Insulin Vial -Nasal Spray -[MEDICATION NAME] Tablets An interview with RN #219, on 06/25/19 at 11:35 AM, revealed all medications should be labeled and dated when opened.",2020-09-01
372,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,812,E,0,1,S31911,"Based on observations and staff interview, the facility failed to ensure foods are handled and stored in a manner that follow proper sanitary techniques. Issues such as foods not being labeled or dated, equipment in need of cleaning and stored improperly were noted. In addition temperatures were not being monitored of individual refrigerators being kept in resident rooms. This practice has the potential to affect more than a limited number of residents who are served foods from this central location. Facility census: 134 Findings included: a) During the initial tour of the dietary department on 06/24/19 prior to lunch the following issues were noted. The dietary manager was with the surveyor at the time of the observations and verififed the violations noted: 1. Walk in refrigerator, chicken patties were opened and out of the original container stored in a plastic bag. The bag contained no date of when it had been opened which would allow dietary staff to determine how fresh the product was and if safe for consumption. 2. Drip pans located under the range tops contained a large amount of food debris and were in need of cleaning. 3. Oven had food spills on the side near the range top and these could be removed easily with the fingertip. 4. Serving utensils were stored in a drawer all jumbled up and this practice could lead to the potential of cross contamnation when reaching in to get the handle of one and touching the serving portion of another item in the drawer. b) Personal refrigerators A review of the Resident Refrigerator Policy on 06/25/19 revealed Housekeeping was to check all resident refrigerators for thermometers that read between 32 degrees - 40 degrees. The temperatures are documented daily on the Refrigerator Log sheets for each resident refrigerator located on the (New) Third floor. A review of the clip board located in the Housekeeping closet used to document the daily temperatures for the fourteen (14) resident refrigerators revealed no documented temperatures on 06/24/19 and 06/25/19. During an interview with E154, Housekeeping (HSKKP) on 06/25/19 at 3:10 PM, stated she had not documented any temperatures for the resident refrigerators for 06/24/19 and 06/25/19. She also reported she was not aware she was to document the temperatures on the Refrigerator Log sheets. In an interview with the Housekeeping Supervisor on 06/25/19 at 3:20 PM, verified she would do training with E154 regarding documenting daily temperatures for the resident refrigerators.",2020-09-01
373,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,842,D,0,1,S31911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain complete and accurate medical records. A resident's nurses notes contained the wrong medication in a note concerning notification to the responsible party for an order change. This practice affected one (1) of thirty (30) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifier: #12. Facility census: 134. Findings included: a) Medical Record Review A review of the Resident's medical record, on 06/25/19 at 2:00 PM, revealed a Physician Recommendation Form with the dose reduction order [MEDICATION NAME] 10 milligrams daily decreased to [MEDICATION NAME] 5 milligrams daily dated 04/14/19. A review of the Nurses Notes, on 06/25/19 at 2:15 PM, revealed a note written by LPN #191 daughter refused pharmacy recommendations for [MEDICATION NAME] to be decreased dated 04/16/19. b) Interview An interview with the Alzheimer Unit-Nurse Manager (AU-UM), on 06/25/19 at 2:30 PM, revealed the nurses note should have read [MEDICATION NAME] and not [MEDICATION NAME]. The AU-UM stated the note was innacurate due to the Resident not being ordered [MEDICATION NAME].",2020-09-01
374,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,880,E,0,1,S31911,"Based on observation and staff interview, the facility failed to provide and maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infection in the laundry area. The facility failed to provide a separation to prevent airflow from cross- contamination of linens and failed to maintain clean surfaces to store linens and positioning devices. This practice had the potential to affect more than a limited number of residents. Facility census: 134. Findings included: An observation on 06/25/19, at 03:20 PM, revealed the door to the soiled utility room was open to the hallway entrance. Eight (8) bins/containers of uncovered soiled linens and clothing were observed in the soiled utility area. Additionally, there was no separation to prevent air flow from the soiled utility into the clean area causing cross contamination of clean linens. When standing on the designated clean side, air was moving by a floor fan and could be felt moving toward the clean side. Linens were being dried and folded by staff. An interview, on 06/25/19, at 03:20 PM, with the Housekeeping Supervisor, verified, there was an exhaust fan behind the dryers that was operable, but the exhaust fan did not prevent the air from flowing from the soiled area to the clean side. An additional fan was being used in the open space between the soiled and clean side. This fan was running and both sides were covered with lint and debris. The Housekeeping supervisor stated this fan was used because it was hot in there and needed for comfort and confirmed the fan was covered on both sides of the protective screen with lint and debris and was blowing air from the dirty to the clean area. Observations of the shelving in the clean utility room on 06/25/19 at 03:40 PM, revealed. the shelves were dust covered and when swiped with a finger, left a clean streak. Clean linens were stored on the shelves. A positioning pillow was observed on the bottom shelf with some of the pillow touching the floor. An interview with the Administrator, on 06/26/19, at 08:40 AM, revealed there has never been a separation between the soiled and clean side of the laundry.",2020-09-01
375,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,883,D,0,1,S31911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of Centers for Disease Control (CDC)recommendations, the facility failed to ensure each resident received pneumococcal vaccines in accordance with accepted guidelines. This was evident for two (2) of five (5) residents who were eligible to receive a vaccine. Resident identifiers: R#15, and R#115. Census: 134 Findings included: a) Resident #15 (R#15) A review of the medical record for R#15, on 06/26/19 at 08:15 AM, noted R#15 was admitted to the facility on [DATE] and a consent for pneumococcal vaccinations was signed to accept the vaccination on this date. The record showed the resident had received the Prevnar 13 vaccination in (YEAR). Further review of the medical record did not show any record of a [MEDICATION NAME] 23 (PPSV23) being administered since the resident's admitted . An interview, on 06/26/19 at 08:21 AM, with RN#230, verified R#15 was eligible for PPSV23, but had not received it to date. b) Resident #115 (R#115) A review of the medical record for R#115, on 06/26/19 at 08:25 AM, showed an admission date of [DATE] and a consent signed by the legal representative, on 03/08/19, consenting to the administration of the pneumococcal vaccination. Further review of the record did not show any record of a pneumococcal vaccination being administered since the resident's admitted . An interview, on 06/26/19, at 08:31 AM, with RN#230, verified R#115 was eligible for the Prevnar 13 (PCV13) vaccination and to date the vaccination had not been administered. An interview with the Assistant Administrator on 06/26/19, at 08:52, confirmed understanding that R#115 was eligible and should have received the vaccine. c) Policy and Procedure An interview with RN#152 on 06/26/19, at 07:05 AM, revealed the facility follows Centers of Disease Control (CDC) guidelines for vaccinations and was also verified by the Assistant Administrator in a follow-up interview on 06/26/19 , at 08:52 AM. A review of Centers for Disease Control Guidelines , noted that PCV13 is to be administered one year after the date of receiving PPSV23. Additionally, if an adult received the PCV13 first, the PPSV23 would be administered one year from when the PCV13 vaccination was received.",2020-09-01
376,GOOD SHEPHERD NURSING HOME,515038,159 EDGINGTON LANE,WHEELING,WV,26003,2017-01-11,253,E,0,1,PS4J11,"Based on observation and staff interviews the facility failed to ensure metal floor plates were secure, corner moldings and trim were secure, handrail compartments were clean, and wall paper was intact. These findings had the potential to affect more than a limited number of residents. Room Numbers: #348, #352, #350, and #355 and second and third floor resident corridors. Facility census: 183. Findings include: a) Observations 1. Observations on 01/10/16 at 12:00 p.m. revealed the following: --Second floor corridor had a corner with a protruding metal floor plate. --Second floor corridor outside Room #246 had trim molding with a protruding corner. --The third floor corridor adjacent from the nursing station had a non-secure plastic corner piece on the handrail. --Second floor corridor had intermittent soiled handrail compartments. --Third floor corridor had intermittent soiled handrail compartments. 2. An observation of Room #352 on 01/10/17 at 12:00 p.m. revealed this room had detached wallpaper. 3. On 01/09/17 at 4:48 p.m. an observation in Room #350 revealed the room had detached wallpaper behind the sink. 4. An observation on 01/09/17 at 2:43 p.m. revealed Room #355 had detached and damaged wallpaper behind the sink and behind the bed. 5. At 4:40 p.m. on 01/09/17 revealed Room #348 had detached and missing wallpaper behind the sink and adjacent to the bed. 6. Cracked floor tiles were observed throughout second and third floor resident corridors. b) Interviews On 01/11/17 at 9:06 a.m. during a facility tour, Housekeeping Supervisor (HS) #69 stated that the protruding corner of a metal floor plate had been a problem and acknowledged that the protruding plate on the second floor corridor was a trip hazard to residents. HS #69 placed a caution sign atop the protruding metal floor plate. HS #69 acknowledged that the observed corner trim molding protruding from the wall was a potential hazard to residents. HS #69 stated that the non-secure plastic corner piece of the handrail should be secured.HS #69 also stated that the observation of intermittent soiled handrail compartments on second and third floor corridors was not the expectation of facility standards. HS #69 indicated that the observed detached wall paper in resident Rooms #352, #348, #350 and #355 would require wall covering repair and/or replacement including the application of plexi-glass protective barriers to minimize the re-currence of damage. HS #69 stated that the observed cracked floor tiles throughout the second and third floor resident corridors were being reviewed for replacement flooring options. During an interview with the administrator, on 01/11/17 2:25 p.m., the administrator stated plans to renovate the facility were in progress.",2020-09-01
377,GOOD SHEPHERD NURSING HOME,515038,159 EDGINGTON LANE,WHEELING,WV,26003,2017-01-11,280,D,0,1,PS4J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure Resident #19's care plan was revised when he sustained a change and/or increase in behaviors. This was evident for one (1) of fifteen (15) Stage 2 sampled residents. Resident identifier: #19. Facility census: 183. Findings include: a) Resident #19 Review of the medical record found pertinent [DIAGNOSES REDACTED]. His wife also resided at the facility. The brief interview for mental status (BIMS) score was six (6), which indicated severe cognitive impairment for decision making. During medical record review, the quarterly minimum data set (MDS) with assessment reference date (ARD) 10/25/16, assessed that he had incidents of physical behaviors directed toward others which occurred one (1) to three (3) days in the look back period. In comparison, his admission MDS, with ARD 08/08/16, assessed that he had no behaviors directed toward others in that look back period. During an interview with MDS registered nurse #11 on 01/10/17 at 3:30 p.m., she said the nurse aides documented he had one (1) episode of sexual behaviors on 10/19/16, and one (1) instance of wandering a few days later. She corroborated the wandering behaviors with nursing progress notes. She did not know what type of sexual behavior he exhibited on 10/19/16. Review of the care plan at this time found he had a care plan focus and individualized interventions for wandering, but nothing related to sexual or other types of behaviors. MDS nurse #11 said they probably would not have care planned for only an isolated instance of sexual behaviors. Review of the medical record found numerous instances of behaviors recorded in nurse progress notes as follows: --On 08/20/16, a nurse aide reported he pulled his wife's hair and told her to knock it off. Also,his wife was heard yelling from the bathroom. The resident stood outside the bathroom door and told the wife not to make him come in there and choke her. Staff separated the two (2) residents and monitored them. --On 11/17/16, he wandered into another resident's room and tried to get into a female resident's bed, thinking it was his wife. The other resident scratched him. --On 11/18/16, he yelled at other residents while eating supper in the dayroom, but was easily redirected. --On 11/28/16, he was very agitated on the first part of the shift, combative with staff, and grabbed staff by the throat. Staff was unable to redirect him without causing more agitation. --On 11/30/16,, the resident was (typed as written) very sexual harassment to female staff doing p.m. (evening) cares. --On 12/10/16, he yelled and became agitated with his wife. Redirection and 1:1 was successful. An interview was completed with registered charge nurse (RN) #49 on 01/10/17 at 3:55 p.m. She said she was unaware of any sexually acting out behaviors except for that recorded in nurse progress noted on 11/30/16. She said she would not have updated the care plan based on that one instance. She said there is no record of sexual behaviors occurring on 10/19/16 except for the one (1) checkmark in the column denoting sexual behaviors that was entered into the computer by a nursing assistant. The check mark does not describe what he may have done that day. She said she wondered if it may have been check marked in error. An interview was completed with registered charge nurse (RN) #193 on 01/11/17 at 1:00 p.m. She said due to an increase in his behaviors, she thought the care plan should have been revised. To remedy that problem, she said she revised the care plan today to include a focus related to sexually inappropriate behaviors with his wife and staff. She said she also revised the care plan to include a focus related to behaviors of frequently yelling at his wife, and behaviors of frequently yelling at staff with activities of daily living cares. She also revised the care plan to include some individualized interventions for those behaviors.",2020-09-01
378,GOOD SHEPHERD NURSING HOME,515038,159 EDGINGTON LANE,WHEELING,WV,26003,2017-01-11,371,E,0,1,PS4J11,"Based on observation, staff interview, and policy review, the facility failed to serve food in a sanitary manner. Residents were observed receiving meal trays served by staff members who failed to wash and/or sanitize their hands after having first touched inanimate objects prior to the tray serve. This practice had the potential to transmit disease causing organisms via cross contamination from unclean surfaces to residents' dining equipment. Although this had the potential to affect more than a limited number of residents who received meal trays on the 300 North unit, it directly affected four (4) of the residents observed. Resident identifiers: #71, #54, #97, #100. Facility census: 183. Findings include: a) Resident #71 Because of outbreaks of gastrointestinal illness and respiratory infections within the facility, the facility served meals to the majority of residents in their rooms. The main dining rooms were closed temporarily in an effort to quarantine to help decrease the spread of illness among residents until the outbreaks subsided. During observation of the meal service to residents on 01/09/17, nurse aide (NA) #46 served a tray to Resident #130 in Room #305 at 1:10 p.m The NA moved the plastic drink cup on her over-bed table with bare hands, while placing her tray of food in front of her. Without washing and/or sanitizing hands, NA #46 obtained unwrapped silverware from the metal silverware holder on top of the food cart with bare hands, then obtained a tray for Resident #71 and served it to her at 1:15 p.m. This same NA removed the lid from her meal tray, and placed the lid atop the resident's plastic, pink water pitcher. NA #46 then assisted the resident by setting up her tray. Tray set up consists of things such as removing lids, opening and placing straws in drinks, removing bread from its package and buttering it, and ensuring the resident had enough room on the over-bed table for the meal tray. The NA then picked up the lid from atop the resident's plastic water pitcher, and placed it on top of the food cart which was located in the hallway. b) Resident #54 On 01/09/17 NA #46 left Resident #71's room after delivering her lunch tray. Without washing and/or sanitizing hands, this NA obtained unwrapped silverware from the metal silverware holder located on top of the food cart, using bare hands. NA #46 then obtained a tray for Resident #54 from the food cart and served it to Resident #54 at 1:15 p.m NA #46 moved items from the resident's overbed tray, opened up straws and placed them in her drink with bare hands. Next, the NA rummaged in the resident's bedside table as if looking for something. c) Resident #97 On 01/09/17 NA #46 left Resident #54's room after delivering her lunch tray, and after touching items in her room with bare hands. Without washing and/or sanitizing hands, this NA obtained unwrapped silverware from the metal silverware holder located on top of the food cart, using bare hands. NA #46 then obtained a tray for Resident #97 from the food cart and served it to Resident #97 at 1:20 p.m. d) Resident #100 1. On 01/09/17 at 1:30 p.m., a different NA, name unknown, responded to Resident #237 in a different room where an alarm was sounding. She turned off the alarm. Before leaving the room, the NA raised the Resident #237 upper half side rail with her bare hands. Without washing and/or sanitizing hands, the NA obtained unwrapped silverware from the metal silverware holder located on top of the food cart with bare hands. This NA then obtained and delivered a tray to Resident #100 (residing in a different room than Resident #237). She placed the tray on his over-bed tray,then left the room. 2. On 01/09/17 at 1:33 p.m., a wandering resident from another unit (Resident #217) entered Resident #71's room. The wandering resident picked up Resident #71's pink, plastic water pitcher and drank from it. The wandering resident stepped outside the room into the hallway, and slid one (1) hand into her trousers down to the region of the crotch. She then removed the hand from her trousers and re-entered Resident #71's room. She again picked up the pitcher and drank from it. This was brought to staff's attention as none had witnessed this incident. Nurse Aide (NA) #155 took Resident #71's pink, plastic water pitcher and placed it on a rack with other dirty dinnerware. Without first washing and/or sanitizing hands, NA #155 sat down beside Resident #100 on 01/09/17 at 1:36 p.m., and began assisting him to eat his meal. e) Interviews and policy review An interview was conducted with third floor north unit registered nurse (RN) #61 on 01/10/17 at 12:34 p.m. Upon inquiry, she said she expected staff to wash and/or sanitize their hands between tray serves if they touched objects or residents during a tray serve. She was informed of the afore mentioned situations where this protocol was not followed by several staff members on yesterday's lunch meal serve on this unit. She said she would take care of this right away, and would educate staff prior to 01/10/17's lunch tray service in the residents' rooms. On 01/11/17 at 12:00 p.m., the administrator provided a copy of the facility's hand-washing/Hand Hygiene policy. The policy provided stated under number one (1), All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. Number two (2) stated, All personnel shall follow the hand-washing/hand hygiene procedures to help prevent the spread of infections to to other personnel, residents, and visitors. Number five (5) stated, Use soap (antimicrobial or non-antimicrobial) and water or an alcohol-based hand rub containing at least 62% alcohol (when indicated) for the following situations .before and after direct contact with residents .before and after assisting a resident with meals.",2020-09-01
379,GOOD SHEPHERD NURSING HOME,515038,159 EDGINGTON LANE,WHEELING,WV,26003,2017-01-11,441,E,0,1,PS4J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to implement and maintain an infection control program to provide a safe, sanitary, and comfortable environment. This failed practice had the potential to affect more than a limited number of residents residing in the facility. Practices to prevent the transmission of infection were not exercised in regards to unclean handrails observed throughout the facility. Employee hand hygiene observed during meal service was not consistent with standards of practice to reduce spread of infection and reduce cross contamination. Resident identifiers: #130, #54, #97, #100, and #71. Facility census: 183. Findings include: a) Handrails On 01/11/17 at 9:06 a.m. during a facility tour, Housekeeping Supervisor #69 stated that the observation of intermittent soiled handrail compartments on second and third floor corridors was not the expectation of facility standards. Hand Hygiene b) Resident #130 During observation of the meal service to residents on 01/09/17, Nursing Assistant (NA) #46 served a tray to Resident #130 in room [ROOM NUMBER] at 1:10 p.m The NA moved the plastic drink cup on her over-bed table with bare hands, while placing her tray of food in front of her. Without washing and/or sanitizing hands, NA #46 obtained unwrapped silverware from the metal silverware holder on top of the food cart with bare hands, then obtained a tray for Resident #71 and served it to her at 1:15 p.m. This same NA removed the lid from her meal tray, and placed the lid atop the resident's plastic, pink water pitcher. NA #46 then assisted the resident by setting up her tray. Tray set up consists of things such as removing lids, opening and placing straws in drinks, removing bread from its package and buttering it, and ensuring the resident has enough room on the over-bed table for the meal tray. The NA then picked up the lid from atop the resident's plastic water pitcher, and placed it on top of the food cart which was located in the hallway. c) Resident #54 On 01/09/17 NA #46 left Resident #71's room after delivering her lunch tray. Without washing and/or sanitizing hands, this NA obtained unwrapped silverware from the metal silverware holder located on top of the food cart, using bare hands. NA #46 then obtained a tray for Resident #54 from the food cart and served it to Resident #54 at 1:15 p.m NA #46 moved items from the resident's overbed tray, opened up straws and placed them in her drink with bare hands. Next, the NA rummaged in the resident's bedside table as if looking for something. d) Resident #97 On 01/09/17 NA #46 left Resident #54's room after delivering her lunch tray, and after touching items in her room with bare hands. Without washing and/or sanitizing hands, this NA obtained unwrapped silverware from the metal silverware holder located on top of the food cart, using bare hands. NA #46 then obtained a tray for Resident #97 from the food cart and served it to Resident #97 at 1:20 p.m. e) Resident #100 On 01/09/17 at 1:30 p.m., a different nursing assistant, name unknown, responded to a resident in room [ROOM NUMBER] where an alarm was sounding. She turned off the alarm. Before leaving the room, the aide raised the resident's (fairly new resident, #237) upper half side rail with her bare hands. Without washing and/or sanitizing hands, the NA obtained unwrapped silverware from the metal silverware holder located on top of the food cart with bare hands. This NA then obtained and delivered a tray to Resident #100. She placed the tray on his over-bed tray,then left the room. f) Resident #71 On 01/09/17 at 1:33 p.m., a wandering resident from another unit (Resident #217) entered Resident #71's room. The wandering resident picked up Resident #71's pink, plastic water pitcher and drank from it. The wandering resident stepped outside the room into the hallway, and slid one (1) hand into her trousers down to the region of the crotch. She then removed the hand from her trousers and re-entered Resident #71's room. She again picked up the pitcher and drank from it. This was brought to staff's attention as none had witnessed this incident. Nursing assistant (NA) #155 took Resident #71's pink, plastic water pitcher and placed it on a rack with other dirty dinnerware. Without first washing and/or sanitizing hands, NA #155 sat down beside Resident #100 on 01/09/17 at 1:36 p.m., and began assisting him to eat his meal. An interview was conducted with third floor north unit registered nurse (RN) #61 on 01/10/17 at 12:34 p.m. Upon inquiry, she said she expected staff to wash and/or sanitize their hands between tray serves if they touched objects or residents during a tray serve. She was informed of the afore mentioned situations where this protocol was not followed by several staff members on yesterday's (01/09/17) lunch meal serve on this unit. She said she would take care of this right away, and would educate staff prior to today's lunch tray serve in the residents' rooms. On 01/11/17 at 12:00 p.m., the administrator provided a copy of the facility's hand-washing/Hand Hygiene policy. The policy provided stated under number one (1), All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. Number two (2) stated, All personnel shall follow the hand-washing/hand hygiene procedures to help prevent the spread of infections to to other personnel, residents, and visitors. Number five (5) stated, Use soap (antimicrobial or non-antimicrobial) and water or an alcohol-based hand rub containing at least 62% alcohol (when indicated) for the following situations .before and after direct contact with residents .before and after assisting a resident with meals. These findings were discussed with the director of nursing (DON), on 01/11/17 at 2:15 p.m., and she verbalized understanding.",2020-09-01
380,GOOD SHEPHERD NURSING HOME,515038,159 EDGINGTON LANE,WHEELING,WV,26003,2018-03-28,550,D,0,1,T7WG11,"Based on observation, staff interview and policy review, the facility failed to promote dignity for two of 35 residents by posting personal care information and instructions above resident's beds in a viewable manner. This had the potential to affect a limited number of residents. Resident identifiers #95 and #97. Facility census: 176. Findings included: a) Resident #95 An observation on 03/27/18, at 8:37 AM, revealed an orange sign posted above Resident #95's bed disclosing personal care information noting to crush meds and administer through peg tube. b) Resident #97 An observation on 03/27/18, at 1:50 PM, revealed a sign posted above Resident 97's bed in a viewable area disclosing personal information about the residents swallowing problem. c) Staff interview An interview with Staff #162, on 03/27/18 at 1:50 PM, revealed signs are posted above beds for direction but a notebook is available at each bedside for placement of personal care information to protect it from view. d) Facility policy A review of the undated facility policy titled Confidentiality of Information and Personal Privacy revealed, The facility will safe guard the personal privacy and confidentiality of all residents' personal and medical records.",2020-09-01
381,GOOD SHEPHERD NURSING HOME,515038,159 EDGINGTON LANE,WHEELING,WV,26003,2018-03-28,684,D,0,1,T7WG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure two of 35 sampled residents, received care and treatment according to the resident's plan of care to maintain the highest level of personal functioning. Resident identifiers: #97 and #38. Facility census: 176. Findings included: a) Resident #97 1. Right palm guard A review of the medical record of Resident #97 revealed a current physicians order for the resident to wear a right palm guard at all times except for hygiene and range of motion. Observations of Resident #97 on 03/26/18 at 01:33 PM, 03/27/18 at 08:40 AM and 03/27/18 at 01:44 PM, revealed no right palm guard present. During the observations made, Resident #97 was not receiving range of motion or hygiene care. An interview on 03/27/18 at 01:44 PM, with Staff #162 verified the right palm guard for Resident #97 was not present on the resident's right hand. It was further verified the order was for the resident to have the right palm guard on at all times except for range of motion and hygiene. 2. Floor mat A review of the medical record for Resident #97 revealed a current physician's orders [REDACTED]. A review of the current care plan, dated 01/17/18, revealed this resident to be a high risk for falls and was to have the floor mat by the bed for safety. An observation of Resident #97's room on 03/27/18 at 08:44 AM, revealed no floor mat in place beside Resident #97's bed. An additional observation on 03/27/18 at 01:50 PM, revealed no floor mat beside the bed of Resident #97. An interview on 03/27/18 at 01:50 PM, with Staff #162, confirmed the order to have a floor mat beside the bed for Resident #97 was a current order and current care plan intervention. It was further stated, the floor mat had mistakenly been placed beside another resident's bed and not by Resident #97's bed as ordered by the physician and directed by the resident's plan of care. b) Resident #38 Review of medical records reveal a physician order [REDACTED]. Continued review of the medical records revealed no evidence the blood pressure was obtained as ordered. A blood pressure summary report revealed documented blood pressures two times for the month of (MONTH) (YEAR), two times for the the month of (MONTH) (YEAR), and two times for the month of (MONTH) (YEAR). On 03/28/18 at 8:42 AM the facility director of nursing (DON) agreed the blood pressure values ordered by the physician were not documented in the medical records.",2020-09-01
382,GOOD SHEPHERD NURSING HOME,515038,159 EDGINGTON LANE,WHEELING,WV,26003,2019-05-15,656,D,0,1,1KH411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to implement a comprehensive person-centered care plan for three of 35 residents reviewed . The facility failed to provide pressure relieving devices, failed to provide the correct oxygen administration flow rate and failed a cover a wound as outlined in the comprehensive person-centered care plan. Resident identifiers: # 147, #158 and #78. Facility census 180. Findings included: a) Resident #147 (R#147) Record review on 05/14/19 at 7:49 AM, noted the comprehensive person-centered care plan for R#147 had a problem identified for a potential risk for impairment in skin integrity. As an intervention, R#147 was to receive pressure relieving devices while in bed and in the chair. A wedge was ordered to be placed under the left leg to float the heel while in bed. An observation made with RN#63, on 05/14/19 at 7:54 AM, verified there was no wedge under the left leg of R#147. RN#63 retrieved a wedge on the TV stand and stated, we will correct that. An interview, on 05/14/19 at 2:20 PM, with the Assistant Director of Nursing (ADON) verified the wedge should have been in place. b) Resident #158 During observation on 05/13/19 at 2:56 PM, Resident #158 sat in her chair. She wore oxygen per nasal cannula at 3 liters per minute as delivered from an oxygen concentrator. The record reviewed on 05/14/19 revealed a the current care with a revision date of 04/17/19 for an oxygen setting of 4 liters (continuous) per minute via nasal cannula. Observation on 05/14/19 at 10:49 AM found her using her oxygen at 3 liters per minute, rather than at 4 liters per minute as the care plan directed. An interview conducted with registered nurse supervisor #41 (RN #41) on 05/14/19 at 11:00 AM verified the resident's oxygen concentrator was delivering oxygen at 3 liters per minute per nasal prongs, rather than at 4 liters per minute as the care plan directed. Upon inquiry, she said this resident does not reset the oxygen settings by herself. Rather, nursing sets the flow rate for oxygen delivery. RN #41 then adjusted the flow rate to four (4) liters per minute at this time. This failure to implement and/or follow the care plan was relayed to the director of nursing (DON) on 05/15/19 at approximately 9:30 AM. No further information was provided prior to exit. c) Resident #78 An observation, on 05/13/19 at 11:40 AM, revealed Resident #78 had a visible bloody wound on forehead. The wound was open to air and was not covered. A second observation, on 05/13/19 at 1:30 PM, revealed Resident #78 continued to have an uncovered wound on forehead that remained uncovered. A record review of the physician orders [REDACTED]. The physician order [REDACTED]. The care plan stated, 3/21/19- clean right side of forehead with NS, apply band aid daily. An interview with Licensed Practical Nurse (LPN) #152, on 05/13/19 at 1:35 PM, confirmed Resident #78's wound on forehead should be covered per care plan and physician order. LPN #152 stated that Resident #78 has been known to take off the bandaid. A record review of care plan, on 05/14/19, revealed the behavior of removal of bandaid from forehead wound by Resident #78 had not been care planned. Care plan had not been revised to reflect Resident #78's behavior.",2020-09-01
383,GOOD SHEPHERD NURSING HOME,515038,159 EDGINGTON LANE,WHEELING,WV,26003,2019-05-15,657,D,0,1,1KH411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to revise the resident's person-centered comprehensive care plan to meet the resident's medical and physical needs. The facility failed to revise the care plan to reflect the resident's behavior of band-aid removal that exposed wound on forehead. The failed practice affected one (1) of 35 residents. Resident identifier: #78. Facility census: 180. Findings included: a) Resident #78 An observation, on 05/13/19 at 11:40 AM, revealed Resident #78 had a visible bloody wound on forehead. The wound was open to air and was not covered. A second observation, on 05/13/19 at 1:30 PM, revealed Resident #78 continued to have an uncovered wound on forehead that remained uncovered. A record review of the physician orders [REDACTED]. The physician order [REDACTED]. The care plan stated, 3/21/19-clean right side of forehead with NS, apply band aid daily. An interview with Licensed Practical Nurse (LPN) #152, on 05/13/19 at 1:35 PM, confirmed Resident #78's wound on forehead should be covered per care plan and physician order. LPN #152 stated that Resident #78 has been known to take off the band-aid. A record review of care plan, on 05/14/19, revealed the behavior of removal of band-aid from forehead wound by Resident #78 had not been care planned. Care plan had not been revised to reflect Resident #78's behavior.",2020-09-01
384,GOOD SHEPHERD NURSING HOME,515038,159 EDGINGTON LANE,WHEELING,WV,26003,2019-05-15,684,E,0,1,1KH411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to follow or clarify physician's orders for residents receiving respiratory care services, pressure relieving devices, and wound care. These practices affected eleven (11) of thirty-five (35) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #153, #150, #372, #2, #119, #171, #77, #147, #158, #274, and #78. Facility census: 180. Findings included: a) Respiratory services 1. Resident #153 A review of the Resident's physician orders, on 05/14/19 at 8:50 AM, revealed the order (MONTH) titrate oxygen to keep oxygen saturation above or equal to 92%. An interview with the Director of Nursing (DON), on 05/14/19 at 1:30 PM, revealed she understood that clear parameters are needed for the titration of oxygen. The DON stated she would get the oxygen order clarified by the physician. 2. Resident #150 A review of the Resident's physician orders, on 05/14/19 at 9:15 AM, revealed the orders Oxygen at 3 Liters via nasal cannula continuously-may titrate to keep oxygen saturation above 90%. and (MONTH) titrate oxygen to keep oxygen saturation at or above 92%. An interview with the DON, on 03/05/19 at 1:30 PM, revealed there were two different orders for oxygen The DON stated clear parameters are needed for the titration of oxygen. The DON stated she would get the oxygen order clarified by the physician. 3. Resident #372 A review of the Resident's physician orders, on 05/14/19 at 9:30 AM, revealed the order (MONTH) titrate oxygen to keep oxygen saturation at or above 92%. An interview with the Director of Nursing (DON), on 05/14/19 at 1:30 PM, revealed she understood that clear parameters are needed for the titration of oxygen. The DON stated she would get the oxygen order clarified by the physician. 4. Resident #119 Record review on 05/14/19 at 08:54 AM , for Resident #119 , showed a current physician's order noting: may titrate O2 to keep saturation levels greater or equal to 92%. The order was not specific as to the flow rate the oxygen was to be administered. An interview, on 05/14/19, at 1:05 PM , with the Director of Nursing (DON), verified the order was not specific and titration orders were not acceptable practice. 5. Resident #2 Record review on 05/13/19 01:48 PM, for Resident #2, showed a current physician's order noting: may titrate O2 to keep saturations above 90% as needed for low oxygen saturation. The order was not specific as to the flow rate the oxygen was to be administered. An interview, on 05/14/19, at 1:05 PM , with the Director of Nursing (DON), verified the order was not specific and titration orders were not acceptable practice. 6. Resident #77 Record review on 05/13/19 03:03 PM, for Resident #77, showed a current physician's order noting : may titrate O2 to keep saturation greater or equal to 92%. The order was not specific as to flow rate the oxygen was to be administered. An interview, on 05/14/19, at 1:05 PM , with the Director of Nursing (DON), verified the order was not specific and titration orders were not acceptable practice. 7. Resident #171 Record review on 05/14/19 09:36 AM, for Resident #171, showed a current physician's order:, noting: may titrate O2 to keep saturation greater or equal to 92% . The order was not specific as to the flow rate the oxygen was to be administered. An interview, on 05/14/19, at 1:05 PM , with the Director of Nursing (DON), verified the order was not specific and titration orders were not acceptable practice. i) Resident #158 During observation on 05/13/19 at 2:56 PM, Resident #158 sat in her chair. She wore oxygen per nasal canulla at three (3) liters per minute as delivered from an oxygen concentrator. The humidifier bottle was empty and was dated 05/05/19. The oxygen tubing was dated 04/28/19. An interview was conducted with licensed practical nurse #219 (LPN #219) on 05/13/19 at 3:12 PM. She said they typically change residents' oxygen tubings once weekly she thought on Saturdays or Sundays. She observed the resident's oxygen tubing at this time and agreed it was dated 04/28/19. She said it was overdue to be changed. She also observed the resident's humidifier bottle which was empty and was dated 05/05/19. She said they generally replace the humidifier bottles every few days and this one was overdue to be changed. She said she would see that both the oxygen tubing and the humidifier bottle were changed right away. The medical record was reviewed on 05/14/19. Current physician's orders directed to change the oxygen tubing weekly on Sunday night shifts. Review of the Medication Administration Record [REDACTED]. Nursing documented that it was changed on 04/28/19, 05/05/19 and on 05/12/19. However, the resident's oxygen tubing contained the date of 04/28/19 when observed on 05/13/19. Current physician orders directed to change the humidification bottle every three (3) days on the night shift. Review of the MAR indicated [REDACTED]. Nurses documented that it was changed on 05/04/19, 05/07/19, 05/10/19, and 05/13/19. However, the resident's humidification bottle contained the date of 05/05/19 when observed on 05/13/19. Further review of the medical record on 05/14/19 revealed current physician's orders to administer oxygen at four (4) liters per nasal canulla continuously every shift related to [MEDICAL CONDITION]. The current Medication Administration Record [REDACTED]. Observation on 05/14/19 at 10:49 AM found her using her oxygen at three (3) liters per minute, rather than at four (4) liters per minute as the care plan and as the physician's orders directed. An interview was conducted with registered nurse supervisor #41 (RN #41) on 05/14/19 at 11:00 AM. She checked the resident's oxygen concentrator and agreed that it was delivering oxygen at three (3) liters per minute, rather than at four (4) liters per minute as the physician ordered. Upon inquiry, she said this resident does not reset the oxygen settings by herself. Rather, nursing sets the flow rate for oxygen delivery. RN #41 then adjusted the flow rate to four (4) liters per minute. Review of nurse progress notes found that nursing at times ran the oxygen at three (3), rather than four (4) liters, as follows: 04/24/2019 21:30 Health Status Note Note Text: Resident lethargic, CNA (nursing assistant) assist her to eat supper. PO (pulse oximetry) 97% at 3L (three liters). 04/14/2019 20:45 Health Status Note Note Text: Resident had unsteady episode during transfers, and complain of SOB (shortness of breath). PO (pulse oximetry) 96% at 3 (three) liters. Supervisor notified. These findings of not following physician's orders to administer oxygen at four (4) liters per minute, to change the oxygen tubing weekly on Sunday nights, and to change the humidification bottles every three (3) days on the nights shift were relayed to the director of nursing (DON) on 05/15/19 at approximately 9:30 AM. No further information was provided prior to exit. 8. Resident #274 Observations on 05/13/19, 05/14/19, and 05/15/19 found this resident used oxygen per nasal cannula at 2 liters per minute. Review of the medical record on 05/15/19 found physician orders to administer oxygen at two (2) liters per minute. Further review of the medical record found another physician's order which stated: (MONTH) titrate O2 (oxygen)to keep sats > or = 92% (greater than or equal to 92 per cent) as needed. An interview was conducted with the director of nursing (DON) on 05/15/19 at 8 AM. She said the order to titrate oxygen to keep the resident's oxygen saturation level greater than or equal to 92 percent as needed was built into the Point Click Care computer system batches. She said that if a resident gets into respiratory trouble they can put oxygen on them until they can get physician's orders for oxygen. She said they are planning to change that physician's order for oxygen titration to ensure better clarification of oxygen delivery parameters. b) Pressure relieving devices 1. Resident #147 Record review on 05/14/19 at 07:49 AM, noted a current physician's order for Resident #147( R#147) to have a wedge placed under the left leg to float the heel while in bed every shift. An observation made with RN#63, on 05/14/19 at 07:54 AM, verified there was no wedge under the left leg of R#147. RN#63 retrieved a wedge on the TV stand and stated, we will correct that. An interview, on 05/14/19 at 02:20 PM, the Assistant Director of Nursing, (ADON )verified the wedge should have been in place c) Wound care 1. Resident #78 An observation, on 05/13/19 at 11:40 AM, revealed Resident #78 had a visible bloody wound on forehead. The wound was open to air and was not covered. A second observation, on 05/13/19 at 1:30 PM, revealed Resident # 78 continued to have an uncovered wound on forehead that remained uncovered. A record review of the physician orders and care plan, on 05/13/19, revealed the wound should be covered. The physician order stated, Clean right forehead with NS, apply bandaid daily until healed. The care plan stated, 3/21/19-clean right side of forehead with NS, apply band aid daily. An interview with Licensed Practical Nurse (LPN) #152, on 05/13/19 at 1:35 PM, confirmed Resident #78's wound on forehead should be covered per care plan and physician order. LPN #152 stated that Resident #78 has been known to take off the bandaid. A record review of care plan, on 05/14/19, revealed the behavior of removal of bandaid from forehead wound by Resident #78 had not been care planned. Care plan had not been revised to reflect Resident # 78's behavior.",2020-09-01
385,GOOD SHEPHERD NURSING HOME,515038,159 EDGINGTON LANE,WHEELING,WV,26003,2019-05-15,695,E,0,1,1KH411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. Physician orders [REDACTED]. Humidifier bottles and oxygen tubing were also not changed timely. This practice affected nine (9) of twelve (12) residents reviewed for respiratory care services during the Long Term Care Survey Process (LTCSP). Resident identifiers: #153, #150, #372, #2, #119, #171, #77, #158, and #274. Facility census: 180. Findings included: a) Resident #153 A review of the Resident's physician orders, on 05/14/19 at 8:50 AM, revealed the order (MONTH) titrate oxygen to keep oxygen saturation above or equal to 92%. An interview with the Director of Nursing (DON), on 05/14/19 at 1:30 PM, revealed she understood that parameters are needed for the titration of oxygen. The DON stated she would get the oxygen order clarified by the physician. b) Resident #150 A review of the Resident's physician orders, on 05/14/19 at 9:15 AM, revealed the orders Oxygen at 3 Liters via Nasal Cannula continuously-may titrate to keep oxygen saturation above 90%. and (MONTH) titrate oxygen to keep oxygen saturation at or above 92%. An interview with the DON, on 03/05/19 at 1:30 PM, revealed there were two different orders for oxygen The DON stated parameters are needed for the titration of oxygen. The DON stated she would get the oxygen order clarified by the physician. c) Resident #372 A review of the Resident's physician orders, on 05/14/19 at 9:30 AM, revealed the order (MONTH) titrate oxygen to keep oxygen saturation at or above 92%. An interview with the Director of Nursing (DON), on 05/14/19 at 1:30 PM, revealed she understood that parameters are needed for the titration of oxygen. The DON stated she would get the oxygen order clarified by the physician. d) Resident #119 Record review on 05/14/19 at 08:54 AM noted a current physician's orders [REDACTED]. The order was not specific as to flow rate the oxygen was to be administered. e) Resident #2 Record review on 05/13/19 01:48 PM noted a current physician's orders [REDACTED]. The order was not specific as to the flow rate the oxygen was to be administered. f) Resident #171 Record review on 05/14/19 09:36 AM noted a current physician's orders [REDACTED]. The order was not specific as to flow rate the oxygen was to be administered. g) Resident #77 Record review on 05/13/19 03:03 PM, noted a current physician's orders [REDACTED]. The order was not specific as to flow rate the oxygen was to be administered. An interview, on 05/14/19, at 1:05 PM , with the Director of Nursing (DON), verified the orders were not specific and that titration orders were not acceptable practice for Residents #119, #2, #171, and #77. h) Resident #158 During observation on 05/13/19 at 2:56 PM, Resident #158 sat in her chair. She wore oxygen per nasal canulla at three (3) liters per minute as delivered from an oxygen concentrator. The humidifier bottle was empty and was dated 05/05/19. The oxygen tubing was dated 04/28/19. An interview was conducted with licensed practical nurse #219 (LPN #219) on 05/13/19 at 3:12 PM. She said they typically change residents' oxygen tubings once weekly she thought on Saturdays or Sundays. She observed the resident's oxygen tubing at this time and agreed it was dated 04/28/19. She said it was overdue to be changed. She also observed the resident's humidifier bottle which was empty and was dated 05/05/19. She said they generally replace the humidifier bottles every few days and this one was overdue to be changed. She said she would see that both the oxygen tubing and the humidifier bottle were changed right away. The medical record was reviewed on 05/14/19. Current physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Nursing documented that it was changed on 04/28/19, 05/05/19 and on 05/12/19. However, the resident's current oxygen tubing contained the date of 04/28/19 when observed on 05/13/19. Current physician orders [REDACTED]. Review of the MAR found it directed to change the humidification bottle every three (3) days on the night shift. Nurses documented that it was changed on 05/04/19, 05/07/19, 05/10/19, and 05/13/19. However, the resident's current humidification bottle contained the date of 05/05/19 when observed on 05/13/19. Further review of the medical record on 05/14/19 revealed current physician's orders [REDACTED]. The resident's current care plan stated the following: OXYGEN SETTINGS: O2 (oxygen) via nasal prongs @ (symbol for at) 4L (liters) Continuous. The revision date was 04/17/19. The current Medication Administration Record [REDACTED]. Observation on 05/14/19 at 10:49 AM found her using her oxygen at three (3) liters per minute, rather than at four (4) liters per minute as the care plan and as the physician's orders [REDACTED]. An interview was conducted with registered nurse supervisor #41 (RN #41) on 05/14/19 at 11:00 AM. She checked the resident's oxygen concentrator and agreed that it was delivering oxygen at three (3) liters per minute, rather than at four (4) liters per minute as the physician ordered. Upon inquiry, she said this resident does not reset the oxygen settings by herself. Rather, nursing sets the flow rate for oxygen delivery. RN #41 then adjusted the flow rate to four (4) liters per minute. These findings of not changing the oxygen tubing weekly and of not changing the humidification bottle every three (3) days were relayed to the director of nursing (DON) on 05/15/19 at approximately 9:30 AM. The finding of not administering the oxygen at the prescribed flow rate of four (4) liters per minute was also relayed to the DON. No further information was provided prior to exit. j) Resident #274 Observations on 05/13/19, 05/14/19, and 05/15/19 found this resident used oxygen per nasal canulla at 2 liters per minute. Review of the medical record on 05/15/19 found physician orders [REDACTED]. Further review of the medical record found another physician's orders [REDACTED].> or = 92% (greater than or equal to 92 per cent) as needed. An interview was conducted with the director of nursing (DON) on 05/15/19 at 8 AM. She said the order to titrate oxygen to keep the resident's oxygen saturation level greater than or equal to 92 percent as needed was built into the Point Click Care computer system batches. She said that if a resident gets into respiratory trouble they can put oxygen on them until they can get physician's orders [REDACTED].",2020-09-01
386,GOOD SHEPHERD NURSING HOME,515038,159 EDGINGTON LANE,WHEELING,WV,26003,2019-05-15,697,D,0,1,1KH411,"Based on resident interview, staff interview, and medical record review, the facility failed to ensure pain management was provided to a Resident consistent with professional standards of practice. Non-pharmacological interventions were not provided for a resident experiencing pain. This practice affected one (1) of thirty-five (35) residents reviewed for pain management during the Long Term Care Survey Process (LTCSP). Resident identifier: #153 Facility census: 180. Findings included: a) Resident #153 An interview with the Resident, on 05/14/19 at 10:15 AM, revealed the staff does not attempt any non-pharmacological interventions for pain. The Resident stated they just give me medication. An interview with LPN #350, on 05/14/19 at 10:25 AM, revealed she does not attempt any non-pharmacological interventions before giving the Resident her pain medications. A review of the Resident's Care Plan was conducted on 05/14/19 at 10:55 AM. The Care Plan, with an initiation date of 04/05/19, had a focus of Resident is on pain medication therapy with the goal of Resident will be free of any discomfort or adverse side effects from pain medication. The Care Plan did not include any non-pharmacological interventions for pain. Further review of the Resident's medical record, on 05/14/19 at 11:20 AM, revealed no documentation the Resident was receiving non-pharmacological interventions before pain medication was administered. An interview with the Director of Nursing (DON), on 05/14/19 at 12:55 PM, revealed the nursing staff should be offering and implementing non-pharmacological interventions for pain before administering any pain medications. The DON stated she could not find where any non-pharmacological interventions for the Resident were in place.",2020-09-01
387,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2017-03-22,246,D,0,1,49H511,"Based on observation, staff interview and resident interview, the facility failed to provide services with reasonable accommodation of residents' needs. Resident #42's call light was out of reach and coiled behind a large chair against the wall with the button end attached to the head of the bed, while the resident was seated in a wheelchair positioned at the foot of the bed with her back to the head of the bed. This practice affected one (1) of forty (40) residents observed in Stage 1 of the Quality Indicator Survey (QIS). Resident identifier: #42. Facility census: 109. Findings include: a) Resident #42 An observation of Resident #42, during Stage 1 of the QIS on 03/20/17 at 10:45 a.m., revealed the Resident's call light was out of reach, attached to the pillow case at the head of the bed. The resident was seated in a wheelchair at the bottom of the bed. The call light was behind her and out of reach. Resident #42 stated during an interview at the time of the observation, I can never reach my light, I just have to wait till someone passes or comes in because I can't turn around in this chair to reach it. Registered Nurse (RN) #47 entered the room during the interview and verified the call light was not in reach of the resident. She stated, The call light is supposed to be in reach at all times and there is no way she (Resident #42) could have reached her call bell to call for assistance. RN #47 immediately positioned the call light within reach for the resident.",2020-09-01
388,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2017-03-22,278,D,0,1,49H511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the individual assessing and certifying the accuracy of Section [NAME] of Resident #45's 5 day Minimum Data Set (MDS), failed to ensure the assessment was accurate regarding resident behaviors. This was found for one (1) of twenty-two (22) Stage 2 sample residents whose MDS's was reviewed during the Quality Indicator Survey (QIS). Resident identifier: #45. Facility census: 109. Findings include: a) Resident #45 On 03/21/17 at 3:40 p.m., a medical record review revealed Resident #45 was originally admitted to the facility in (MONTH) 2013. He was discharged on [DATE] to an inpatient Hospice facility. His [DIAGNOSES REDACTED]. The Director of Nursing (DON) stated during an interview on 03/21/17 at 3:48 p.m., Resident #45's had intermittent behaviors included resisting care and hitting staff. A continued medical record review, on 12/22/17 at 9:15 a.m., of the 5 day MDS with an assessment reference date (ARD) of 12/30/16, found item E0200, item [NAME] Physical behavioral symptoms directed toward others (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually) coded as 0 Behavior not exhibited. Social Worker (SW) #53 provided copies of behavioral monitoring on 12/22/17 at 9:30 a.m. She explained resident behaviors are documented in the nursing progress notes and Resident #45 must not have had any behaviors during the seven (7) day look back period from 12/30/16. Further medical record review, on 12/22/17 at 9:45 a.m., revealed a nursing progress note dated 12/26/16 at 22:05 (10:05 p.m.) (typed as written), Resident (Resident #45) was quite alert tonight and quite unexpectedly without warning slapped aide across the right cheek during p.m. care as well as punching her in the breast . Upon asking SW #53 for a copy of the previous progress note and after reviewing the progress note, she stated, He certainly had behaviors on that day. MDS coordinator #141 entered the SW office and after reviewing the previous progress note and 5 day MDS, she stated, yes MDS is certainly coded incorrectly for not having any behaviors.",2020-09-01
389,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2017-03-22,280,D,0,1,49H511,"Based on record review and staff interview, the facility failed to revise a care plan when the resident had a change in the brief interview for mental status (BIMS) score. This is true for one (1) of twenty-two (22) records reviewed. Resident identifier: #63. Facility census: 109. Findings include: a) Resident #63 Review of the care plan with a revision date of 08/31/16 revealed the resident had a BIMS of 14 our of 15 which represents the highest level of cognitive functioning. Review of the minimum data set (MDS) with an assessment reference date (ARD) of 02/08/17 revealed the residents BIMS to be nine (9) representing a decline in cognitive functioning. The care plan did not reflect this change. On 03/22/17 at 1:22 p.m., Registered Nurse #141 agreed the care plan should have been updated to represent the decline in cognitive functioning.",2020-09-01
390,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2017-03-22,431,E,0,1,49H511,"Based on observation and staff interview, the facility failed to ensure the secure permanently affixed non-removable storage of a medication subject to abuse (Ativan). This practice has the potential to affect more than an isolated number of residents. Facility census: 109. Findings include: a) An observation of the north hall medication storage area on 03/21/17 at 3:21 p.m., in the company of Licensed Practical Nurse (LPN) #68, revealed a clear locked plastic box containing five (5) vials of Ativan 2 milligram/milliliter (mg/ml) and one (1) thirty (30) ml bottle of Lorazepam 1 mg/0.5 ml. The clear plastic box was secured to a removable rack inside the locked refrigerator. A demonstration revealed both the rack and the locked container could easily be removed from the refrigerator. LPN #68 agreed the shelf was not secured to the refrigerator. On 03/21/17 at 3:22 p.m., the Assistant Director of Nursing (ADON) #47 confirmed the shelf should be secured to the refrigerator.",2020-09-01
391,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2017-03-22,456,E,0,1,49H511,"Based on observation and staff interview, the facility failed to maintain essential equipment in safe operating condition. The two (2) commercial dryers in the laundry area contained a heavy accumulation of lint in the lint filters. The North hall nourishment room refrigerator had a missing grill cover and cracked/split rubber gasket surrounding the refrigerator door. This practice had the potential to affect more than a limited number of residents. Facility census: 109. Findings include: a) On 03/21/17 at 12:45 p.m., during a tour of the laundry area, with Laundry Aide (LA) #11, a heavy accumulation of lint was observed in the lint filters of two (2) of the four (4) commercial clothes dryers. LA #11 stated the filters are cleaned every shift, but acknowledged there was no evidence to show this was done. She commented, we go by the instructions on the lint door that states CLEAN DAILY. Because there was such a heavy amount of lint in each filter, she agreed the lint filters should be cleaned more often, just as she would do with her clothes dryer at home. After viewing the lint filters of the two (2) commercial clothes dryers, at 12:55 p.m. on 03/21/17, the Housekeeping/Laundry (H/L) Supervisor #140 stated, It is a fire hazard and they will be cleaned immediately. She also commented a process and schedule for the cleaning of the lint filters would be set up to maintain the lint filters in a cleaner and safer condition. b) A tour of the North hall nourishment room accompanied by (H/L) Supervisor #140 on 03/21/17 at 2:33 p.m. revealed the refrigerator had a missing grill cover on the bottom of the refrigerator that covers the drip pan and a cracked/split rubber gasket on the bottom of the interior door preventing an adequate door seal. (H/L) Supervisor #140 stated, The refrigerator definitely needs replaced and I will notify maintenance immediately to go and purchase a new refrigerator.",2020-09-01
392,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2018-06-20,582,D,0,1,W8I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of current Centers for Medicare and Medicaid Services (CMS) guidelines and staff interviews, the facility failed to issue appropriate liability and appeal notices. Specifically, the facility failed to issue the Notice of Medicare Non Coverage (NOMNC) letter within the required time frame for three residents (#77, #263, #264) of three sampled residents. Additionally, the facility failed to properly issue the Skilled Nursing Facility Advance Beneficiary Notice of Non Coverage (SNFABN) letter for two residents (#77, #263) of three sampled residents. Resident identifiers: #77, #263, #264. Facility census: 113 residents. Findings included: a) The list of residents discharged in the last six months was provided by the Nursing Home Administrator (NHA) after entrance to the facility on [DATE]. According to the list, Resident #77 remained in the facility after he was discharged from skilled services on both 03/15/18 and 05/31/18. Resident #263 remained in the facility after she was discharged from skilled services on 01/05/18. Resident #264 was discharged home after she was discharged from skilled services on 02/13/18. b) The NONMCs and SNFABNs for Resident #77, Resident #263, and Resident #264 were reviewed on 06/19/18 at 3:25 PM. Review of the NOMNCs and SNFABNS revealed they were not issued in accordance with the guidelines. c) One NOMNC for Resident #77 documented a last covered day of 05/31/18. The resident's Power of Attorney (POA) signed the form on 05/31/18, which was the same day services ended. The second NOMNC for Resident #77 documented a last covered day of 03/15/18. There was no SNFABN issued with the NOMNC. d) The NOMNC for Resident #263 documented a last covered day of 01/05/18. The resident signed the form on 01/04/18, which was one day prior to services ending. There was no SNFABN issued with the NOMNC. e) The NOMNC for Resident #264 documented a last covered day of 02/13/18. The resident signed the form on 02/12/18, which was one day prior to services ending. f) Interviews 1) Social worker (SW) #92 was interviewed on 06/19/18 at 4:05 PM. She had worked at the facility for three months. She said the social worker was responsible for issuing the NOMNCs and getting them signed. The NOMNCs had to be issued two days prior to the resident's last covered day. She said the SNFABN was prepared by the Minimum Data Set (MDS) staff and the business office. She issued the NOMNC for Resident #77. She said she called and did a verbal notification with the resident's Power of Attorney (POA). The POA could not get to the facility for a couple days to be able to sign it. She did not complete the verbal portion of the NOMNC since the POA could sign the paper at a later date. She recognized she should have completed the verbal portion and the NOMNC would have been issued on time. She looked in the resident's chart and she did not have a progress note related to the conversation with the POA about the resident's last covered day. 2) SW #138 was interviewed on 06/19/18 at 4:24 PM. She had worked at the facility for one year. She issued the NOMNC for Resident #263. She said she could not get in touch with the resident's POA in order to get the NOMNC completed on time. She knew she did not get the NOMNC completed in time and took responsibility for it. She did not make a progress note regarding trying to get in touch with the PO[NAME] She did not remember the NOMNC for Resident #264, but acknowledged that it was completed late. She did not know why the NOMNC was not issued on time. 3) SW #138 was interviewed on 06/20/18 at 9:29 AM. Her process for when she cannot get in touch with a POA to issue a NOMNC varies based on the situation. She said sometimes they would extend coverage until the POA could be contacted and then issue the NOMNC with the two-day notice. If someone is upset that they did not get the notice on time, they try and see if services could be extended. When she completes a verbal notification, she explains why services are being discontinued for the resident. She explains their right to appeal and the appeal process. For the SNFABN form, she explains what the payment would be and goes over the different options they could choose. She said when a resident received a SNFABN, the MDS staff completed the reason for the resident being discontinued from skilled services and the business office completed the payment portion of the notice. MDS then e-mails the SW team to let them know which NOMNCs and SNFABNs needed issued. 4) MDS staff members #115 and #28 were interviewed on 06/20/18 at 9:37 AM. MDS staff member #115 said anyone who was going to remain in the facility and not return to the community received a SNFABN. The NOMNCs and SNFABNs were to be given two days prior to the resident's last covered day. MDS staff member #28 said they received training on 03/29/18 regarding SNFABNs. They did not complete SNFABNs prior to 03/29/18. 5) The Business Office Manager (BOM) was interviewed on 06/20/18 at 10:41 AM. She said the facility started doing SNFABNs after they received training on 03/29/18. She said the new regulation was not fully understood and there was a lot of confusion related the SNFABN. She completed the estimated cost portion of the SNFABN, MDS completed the reasoning for why the resident was being discharged from services, and SW issued the notice. MDS staff emailed the SW to let them know which notices needed to be provided. She said the SNFABN is given at the same time as the NOMNC. Both notices were to be given two days prior to the resident's last covered day so the resident had time to appeal if they wished to do so. 6) The NHA was interviewed on 06/20/18 at 10:50 AM. She said they had identified that they had an issue with the timeliness for NOMNCs. They knew they weren't issuing the SNFABN as they should. She said she completed an in-service with the staff in (MONTH) (YEAR) to provide education regarding the SNFABNs and NOMNCs. Since the training, the business office asks which NOMNCs need to be given in their morning meeting so she can keep track of them. She reviewed the NOMNC for Resident #77 with the last covered day of 05/31/18. She recognized that the NOMNC was not issued timely and recognized the NOMNC would have been given after their in-service. She said they needed to do a better job with auditing and come up with a better system than what they had been doing. 7) The NHA was interviewed on 06/20/18 at 12:54 PM. She had a call with their company regarding SNFABNs on 03/09/18. She completed the in-service with her staff on 03/26/18. She could not find the sign in sheet for the in-service. They discussed both NOMNCs and SNFABNs. An audit tool was a part of the training, but they had not been using it. She said all NOMNCs and SNFABNs should be given two days prior to the resident's last covered day. g) Review of the current guidelines for the Centers of Medicare and Medicaid Services instructions for the NOMNC letters of notice, revealed in pertinent part, .The NOMNC must be delivered at least two calendar days before Medicare covered services end .The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice . If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee's services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. When direct phone contact cannot be made, send the notice to the representative by certified mail, return receipt requested . Refer to https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/Instructions-for-Notice-of-Medicare-Non-Coverage-NOMNC.pdf Review of the current guidelines for the Centers for Medicare and Medicaid Services instructions for the SNFABN letters of notice, revised 1/2018, revealed in pertinent part, .Medicare requires SNFs (skilled nursing facilities) to issue the SNFABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers . Refer to https://www.cms.gov/Medicare/Medicare-General-Information/BNI/FFS-SNFABN-.html",2020-09-01
393,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2018-06-20,805,E,0,1,W8I811,"Based on observation, record review and staff interviews, the facility failed to ensure food was prepared in a form to meet individual needs of residents receiving a pureed diet. The facility failed to ensure proper pureed texture for approximately 12 of 12 residents receiving pureed food texture. Facility census: 113. Findings included: The main kitchen was observed on 06/20/18 beginning 8:58 AM. The Assistant Dietary Manager (ADM) #25 stated they had approximately 12 residents receiving pureed texture. At 9:22 AM, Cook #135 was observed pureeing scalloped potatoes. She placed the potatoes into the [NAME]ot Coupe (professional food processor). She added some thickener powder to the food item. She placed the final mixture into a metal pan for the lunch meal. During the taste test, the mixture had large chunks of hard potato pieces throughout. Dietary Manager (DM) #129 and the ADM completed the taste test and confirmed the mixture had large chunks of potatoes throughout. Cook #135 placed the mixture back into the [NAME]ot Coupe for a second round of processing. She added some liquid into the [NAME]ot Coupe and finished pureeing the food item. The ADM tested the finished product and stated it was still chunky. At 9:31 AM, Cook #135 started her third round of processing. The ADM tasted the food item again and said it was getting there but still had chunks in the mixture. By 9:35 AM, Cook #135 started the fourth round of processing. Taste test revealed the product was smooth with no lumps. At 9:43 AM, Cook #135 began pureeing the carrots with butter and thickener. The ADM tested the food mixture when the cook was finished and said it needed to be processed longer. Review of the Scalloped Potatoes Pureed recipe, provided by the ADM on 06/20/18 at 10:47 AM, revealed Add to food processor and process until fine in consistency. At 11:28 AM on 06/20/18, food was observed on the steam table for lunch meal service. The pureed meatloaf was tested . The meatloaf had chunks of stringy meat pieces throughout the mixture. Review of dysphagia diet: level 1 (pureed) https://www.saintlukeskc.org/health-library/dysphagia-diet-level-1-pureed revealed people on this diet should eat only pureed, pudding-like foods. They should avoid foods with coarse textures: pureed vegetables with no lumps, chunks or seeds. Accessed 6/21/18. The DM and the ADM were interviewed on 06/20/18 at 12:55 PM. They confirmed the pureed texture should have been the consistency of mashed potatoes.",2020-09-01
394,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2018-06-20,812,F,0,1,W8I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility policy review and staff interviews, the facility failed to store, prepare and serve food in accordance with professional standards for food service safety in two of two kitchens. Specifically, the facility failed to ensure the cold food storage was of proper temperature; ensure all foods were covered/sealed; and ensure there were no expired foods. Facility census: 113 residents. Findings included: a) Refrigerator Temperatures The main kitchen was observed on [DATE] at 8:40 AM. The tall beverage refrigerator was 60 degrees. The refrigerator contained cartons of milk, shakes and containers of yogurt. The main kitchen was observed again on [DATE] at 8:50 AM. The tall refrigerator was 50 degrees. At 9:31 AM, the refrigerator was 52 degrees. By 9:35 AM, the Assistant Dietary Manager (ADM) #25 tested the temperature of one milk carton taken from the refrigerator with the temperature of 48 degrees. She stated she would place the refrigerator out of commission. There were approximately 8 cartons of milk and more than 10 containers of yogurt and cartons of shakes. When asked about the temperature log, the ADM said the temperatures were taken and documented when the staff arrived into the kitchen at 5:00 AM. The documentation included temperatures every morning and every night. There was no documentation throughout the day. Review of the Refrigerator Temperature Log revealed the following out of range temperatures: -[DATE]: PM- 48 degrees -[DATE]: PM- 48 degrees -[DATE]: AM- 42 degrees; PM- 49 degrees -[DATE]: AM- 45 degrees -[DATE]: AM- 45 degrees; PM- 55 degrees -[DATE]: AM- 45 degrees -[DATE]: AM- 56 degrees -[DATE]: PM- 60 degrees Review of the Record of Food Temperatures policy, dated [DATE], revealed any cold food temperature above 41 degrees requires correction action. The cold food will be discarded. No food will be served that does not meet the food code standard temperatures. b) Unsealed Food Items The main kitchen was observed on [DATE] at 8:50 AM. The lower right-side shelf of the walk-in refrigerator revealed sliced cheese unwrapped and exposed to the environment. At the time of the observation, the ADM confirmed the product needed to be covered. -The refrigerator to the left of the [NAME]ot Coupe station revealed: a large clear plastic bag of hotdogs, open and exposed; and a clear plastic bag of sliced ham, open and exposed. c) Expired Food Items The main kitchen was observed on [DATE] at 8:50 AM. The walk-in refrigerator revealed two five-pound containers of cottage cheese (1- full and 1- half full) with a best if used by date of [DATE]. The ADM was interviewed, and she confirmed the date on the package was what they used as the expiration date. The activity kitchen was observed on [DATE] at 11:55 AM. The following was revealed in the dry storage area: -Two 19.35-ounce boxes of lemon bar mix was dated with a best by date of [DATE]. -One box of lemon bar mix was dated with a best by date of [DATE]. -Two 19-ounce boxes of raspberry bar mix was dated with a best by date of [DATE]. -One 6-ounce container of old bay seasoning was dated with a best if used by date of [DATE]. Activity Director #10 was interviewed on [DATE] at 11:55 AM. She confirmed this dry storage area contained food items the residents would be eating during activities. At 12:10 PM, she stated she looked through the food about once a month but needed to check for expired foods more often. She would dispose of the expired foods. Dietary Manager (DM) #129 and the ADM were interviewed on [DATE] at 12:55 PM. They confirmed the refrigerator was measuring too high and the food items needed to be covered/sealed. They did not have anything to do with the activity kitchen, but they would do more to help activities ensuring the disposal of expired food items.",2020-09-01
399,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2019-10-02,812,E,0,1,TVX311,"Based on observation and staff interview, e facility failed to label, date, and store food items in a safe and sanitary manner. The facility failed to date, and label food items stored in the walk-in refrigerator and freezer. The facility failed to discard a food item when item was breached with a hole in the container. The failed practice had the potential to affect more than an unlimited number of residents. Facility Census: 110. Findings included: a) Kitchen An observation, on 09/30/19 at 11:50AM, revealed multiple food items that were not labelled or dated. The food items included: --A full tray of Eight (8) ounce glasses of orange juice --A bag of 20 frozen Kielbasa links --Two (2) bags of frozen garlic bread (12 count per bag) --Three (3) 32-ounce bags of frozen okra --One (1) bag of frozen cauliflower --Seven (7) bags of frozen waffles (12 waffles per bag) An additional observation, on 09/30/19 at 11:50AM, revealed a half pint of TruMoo chocolate milk with a hole in the side of carton. The carton of milk leaked in the walk-in refrigerator and when removed from shelf. An interview with Assistant Dietary Manager (ADM), on 09/30/19 at 11:50 AM, confirmed all food items should be labeled. ADM stated; the practice of dating food items had been reiterated to staff on a regular basis. A policy, titled Date Marking for Food Safety with revision date of 02/01/19, was reviewed on 10/02/19. The policy stated, The food shall be clearly marked to indicate the date by which the food shall be consumed or discarded. The marking system shall consist of a label containing the date of opening and the date the item must be consumed or discarded.",2020-09-01
412,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2018-08-24,550,E,0,1,7DWR11,"Based on observation, staff interview and resident interview, the facility failed to deliver meals in a timely manner. The lunch meal on 08/20/28 and the dinner meal on 08/21/18 resulted in approximately an hour wait for residents to receive their meals in the dining room. This practice has the potential to affect more than an isolated number of residents. Census: 99. Findings included: a) On 08/20/18 observation began at 11:42 a.m. with the first trays delivered at 11:51 a.m. Approximately 50 residents were in the dining room and were waiting for meals. At 12:13 p.m. residents were in the dining room with 9 staff present to assist with serving. Some residents were not served at the same table and some were expressing concern about where their meals were. This occurred again on 08/21/18 at lunch. Observations again showed residents were seated in the dining room and waited an extended time for meals to be delivered. When the adminsitrator was asked why there was such a delay in tray service she stated she would have to check. She returned later and explained there was a staff member who was new at being the cook and she had not built her speed up on the tray line. Another dietary staff was then assigned to the tray line and food did come out in a more timely fashion.",2020-09-01
413,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2018-08-24,578,D,0,1,7DWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete the Physician order [REDACTED]. The POST forms were found to be incomplete for Resident #36 and #14. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #36 and #14. Facility census: 99. Findings included: a) Resident #36 A review of the medical record on 08/22/18 revealed the POST form for Resident #36 did not include the physician's printed name or contact phone number. In an interview with the nursing home administrator (NHA) on 08/22/18 at 3:30 PM, verified the POST form did not include the physician's printed name or contact phone number. b) Resident #14 Review of the medical record on 08/22/14 revealed Resident #14 lacks capacity and has a designated health care surrogate (HCS). Resident #14's POST form dated 05/07/18, lacks a signature under section D for the HCS. In addition, Section [NAME] contains staff signatures instead of the HCS contact information. The Director of Nursing (DON) reviewed Resident #14's POST form at 3:20 PM on 08/22/18 and confirmed the above errors.",2020-09-01
414,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2018-08-24,584,E,0,1,7DWR11,"Based on observation and staff interview, the facility failed to provide a home-like environment during meals. Residents who ate in the dining room were not served in a timely manner and residents were not offered a method to wash hands before meals, there was no stimulation offered during meal time and residents were not served at the same time who were seated at the same table. This practice had the potential to affect more than an isolated number of residents. Census: 99. Findings included: a) Observations at lunch on 08/20/18 revealed that residents waiting in the dining room were noted to sit for an extended time, almost and hour before receiving their meals. It was also noted not all residents seated at the same table were served at the same time. Not all residents were seen to be offered hand wipes or any method of washing their hands before meals. This did not create a homelike environment. This occurred again on 08/21/18 at lunch. Not only were residents in the dining room not served in a timely manner but residents who ate in the rooms were not served timely as well. A tray rotation schedule given to the surveyor by the dietary manager on 08/20/18 prior to lunch indicated trays would be delivered in this fashion. One cart to East wing, one cart to west wing, dining room, a second cart to east wing and the the final secord cart to west wing. Staff on the units and in the dining room seemed to be aware that this was the correct rotation. The time line given on a document to surveyors by the adminstrator on 08/20/18 said the tray rotation would be 11:40 cart to west, 11:50 cart to east, 2nd cart to west and then at 12:00 noon the main dining room. This was not the system surveyors observed during the meal time, nor the timeframes that trays would be coming out. Resident council meeting minutes and feedback from the confidential group meeting held at 11:00 a.m. on 08/21/18 showed there was concern with the taste and temperature of the food served at the facility. The Ombudsman also informed surveyors that she had been working with the facility on issues concerning food as well.",2020-09-01
415,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2018-08-24,657,E,0,1,7DWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family interview and staff interview, the interdisciplinary team failed to develop comprehensive care plans and assure each resident and/or their representative were involved in the development of the person centered care plan. Care plans were not updated to reflect changes in treatments and Resident #61's family members were not included in the care plan meetings. This practice has the potential to affect more than a limited number of residents. Resident identifiers: #61, #33, and #36. Facility census: 99. Findings included: a) Resident #61 1) Family included in care plan meeting During an interview on 08/20/18 at 2:30 PM, Resident #61's husband/Health Care Surrogate (HCS) voiced concerns with his wife's impending discharge after receiving a Notice of Medicare Non-Coverage. The husband/HCS reported he nor his children have been invited to the care plan meetings. Review of the medical record on 08/23/18, revealed no information related to Resident #61's family being invited to or attending the care plan meetings. Social Worker #33 reviewed Resident #61's electronic records and reported there is no documentation related to notification of the meetings or the presence of family members at the care plan meetings, during an interview on 08/23/18 at 11:00 AM. 2) Care plan update Review of the medical record on 08/23/18, revealed Resident #61 was admitted to the facility in (MONTH) with a [DEVICE] for feedings. A physician order [REDACTED].#33 pulled out her feeding tube. The care plan was updated on 08/07/18, noting Resident #33 requires total assistance with dining with swallow precautions. Under the activities of daily living focus the care plan states: Eating (name) requires total assist for tube feeding. The Director of Nursing confirmed the care plan was not updated to reflect Resident #33's current nutrition status during an interview on 08/23/18 at 12:30 PM. b) Resident #33 Review of Resident #33's medical record on 08/22/18, revealed a physician's orders [REDACTED]. The current care plan, last revised 08/20/18 lacks any information related to this order. During an interview on 08/22/18, Activities Director (AD) #13, reported she was aware of the order to take Resident #33 outside. Upon review of Resident #33s care plan, AD #13 acknowledged it was not updated to include the order to take the resident out in the sun. c) Resident #36 A medical record review on 08/20/18 for Resident #36, revealed her care plan had not been revised for discontinued [MEDICAL TREATMENT] treatments, her last [MEDICAL TREATMENT] treatment was on 08/06/18. In an interview with the Median Data Set (MDS) Coordinator on 08/21/28 at 9:05 AM verified the care plan had not been revised regarding the discontinued [MEDICAL TREATMENT] treatments for Resident #36.",2020-09-01
416,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2018-08-24,684,E,0,1,7DWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interview, the facility failed to ensure that all treatment and care provided to the residents was provided in accordance with the physician's orders for care for 6 of 20 residents reviewed. The facility failed to ensure that Resident #92 was receiving a bladder training as ordered by the physician and in accordance with the care plan and failed to ensure there was a valid physical's order for day time oxygen administration. Resident #17 did not have compression hose as ordered by the physician and in accordance with the care plan. Resident #36 did not receive splints, have heels floated, non-skid socks in place and the use of a knee separator in accordance with physicians orders and the care plan. Resident #11 was not receiving oxygen therapy in accordance with the physician's order. Resident #90 was observed to have a urinary catheter in place without a physician's order. Activity orders for Resident #33 were not implemented in accordance with physician's orders. Resident identifiers : Resident #92, #17, #36, #11, #90 and #33. Facility census: 99. Findings included: a.) Resident #92 1.) An interview with Resident #92 on 08/21/18, at 8:45 AM, revealed that it takes a long time to answer the light. They { staff} say they will come back and they don't which sometimes results in the resident being incontinent of urine. Resident #92 stated that staff do not ask her to toilet but wait until she asks to go to the bathroom. A review of the medical record for Resident #92 revealed a physician's order for a toileting program every 2 hours and PRN (when necessary) to improve continence. A review of the comprehensive care plan for Resident #92 revealed an intervention for toileting program every 2 hour and PRN. An interview with RN#109 on 08/22/18, at 03:02 PM, revealed the care plan was not developed to outline steps of the toileting program and the program was not being implemented every two hours because of a software issue. It was further stated by RN#109, that the every two hour toileting does not pop up on the Certified Nursing Assistant's (CNA's) Ipad and verified the every two hour toileting intervention was not being implemented. When asked how the program is being implemented, RN#109 stated we're not.'' 2.) An observation of Resident #92, on 08/22/18 at 12:15 PM, revealed Oxygen (O2) being administered to the resident at 2.5 liters per minute. A review of the medical record for Resident #92 revealed the physician's orders were to provide O2 @2l/m at bedtime and on QHS (every hour of sleep) and off in AM, every night shift. An interview with RN#66, on 08/22/18, at 12:20 PM, verified Resident #66 was receiving O2 at 2.5 liters per minute. After looking at the medical record, RN#66, verified the order for the O2 was for bedtime and told LPN#31 we need to take it off of her. An additional interview with RN#66 revealed the facility was doing an incident report on the O2 being placed on the resident without an order. RN#66, further stated the staff should have called the doctor to see if it needed to be PRN (when necessary), and said she educated staff on the correct rate and made this a medication error. b.) Resident #17 A review of the medical record for Resident #17 revealed an order for [REDACTED].>The comprehensive care plan revealed an intervention to have compression hose on in AM and off in PM. Observations on 08/22/18, at 09:56 AM, and 12:00 PM, revealed the resident was dressed and out of bed with no compression stockings on . An interview with Resident #17, on 08/22/18, at 12:00 PM, verified the resident did not have the compression stockings in place and did not have anything but short regular socks available. An interview with LPN#2, on 08/22/18, at 12:55 PM , when asked about the resident wearing the compression hose , she stated ' She does not have them on, I will get her some. An interview and review of the treatment records with RN#66, on 08/22/18, at 1:00 PM, revealed there were no signatures signing off the compression hose being applied during the day and off in the PM and stated they have been ordered since 10/13/17. c) Resident #90 Review of the medical record for the resident on 08/23/18 indicated there was no order for the use of [REDACTED]. The current admission minimum data set assessment dated [DATE] identified a catheter is being used. Discussion with the director of nursing on 08/22/18 at 4:10 p.m. confirmed that the resident does have a catheter and it was being used for retention. Additonally the current care plan did have catheter listed as a problem with interventions in place to provide the care. There was no physician order for [REDACTED]. d) Resident #36 During an observation on 08/22/18 at 12:50 PM for Resident #36 it was discovered her heels were not being floated while in bed, she was not wearing any non-skid socks, there were no ankle/foot orthodics (AFO) applied for foot drop, and the knee separator was not in place to prevent crossing of legs. The current physician's orders are: Float heels on pillow while in bed as a preventative measure start date 11/03/17, Non-skid socks at all times start date 12/23/17, AFO splints to be applied to bi-lateral extremities at 1200 and removed at 1600 start date 05/15/18 and Resident may use knee separator to prevent crossing of legs start date 06/22/18. In an interview and observation with Employee #112, licensed practical nurse (LPN) on 08/22/18 at 1:10 PM verified Resident #36's heels were not being floated on a pillow, the AFO splints were not applied, resident was not wearing any non-skid socks, the AFO splints were not applied to lower extremities and the knee separator was not in place to prevent crossing of legs. Employee #112, LPN agreed the physician orders were not being followed. e) Resident #11 During an observation on 08/22/18 at 9:19 AM it was discovered Resident #11 was not receiving the prescribed amount of oxygen at two (2) liters per minute (LPM). The gauge on the oxygen concentrator was set above 2 LPM. Current physician orders are: Oxygen via nasal cannula at 2 LPM, nurse to check oxygen use every two (2) hours and and as needed (PRN); 1) proper placement of cannula 2) oxygen at correct LPM flow 3) tank is sufficiently filled every 2 hours for oxygen use start date for this order was 06/01/18. In an interview and observation with the assistant director of nursing (ADON) on 08/22/18 at 9:23 AM, she verified the oxygen concentrator was set on 2.5 LPM and not on the correct 2 LPM as ordered. f) Resident #33 Review of Resident #33's medical record on 08/22/18, revealed a physician's order dated 08/01/18 transcribed from a consult report stating: Take Resident outside in the sun for a few minutes daily when possible, per Activity staff. During an interview on 08/22/18, Activities Director (AD) #13, reported she was aware of the order to take Resident #33 outside. AD #13 stated Resident #33 refuses to leave her room. Upon review of the electronic records, AD #13 acknowledged the records are silent in regards to any attempts made by staff to take Resident #33 outside or her refusal to go. During a random observation on 08/23/18 at 1:45 PM, Resident #33 was observed attempting to wheel herself to the door of her room. She stated: They are coming to take me outside at 2:00 (PM).",2020-09-01
417,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2018-08-24,690,D,0,1,7DWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview and staff interview, the facility failed to ensure that services are provided to maintain bladder continence to the extent possible for 1 of 4 residents reviewed for toileting. The facility failed to provide a toileting program as ordered by the physician and addressed in the care plan for Resident #92. Facility census: 99. Findings included: a) Resident #92 An interview with Resident #92 on 08/21/18, at 8:45 AM, revealed, it takes a long time to answer the light. They (staff) say they will come back and they don't which sometimes being incontinent. Resident #92 stated that staff do not ask her to toilet but wait until she asks to go to the bathroom. A review of the medical record for Resident #92 revealed a physician's orders [REDACTED]. A review of the comprehensive care plan for Resident #92 revealed an intervention for toileting program every 2 hour and PRN. An interview with RN#109 on 08/22/18, at 03:02 PM, revealed the care plan was not developed to outline steps of the toileting program and the program was not being implemented every two hours because of a software issue. It was further stated by RN#109, that the every two hour toileting does not pop up on the Certified Nursing Assistant's (CNA's) Ipad and verified the every two hour toileting intervention was not being implemented. When asked how the program is being implemented, RN#109 stated we're not.''",2020-09-01
418,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2018-08-24,744,D,0,1,7DWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations and staff interview, the facility failed to develop and implement a care plan to address the individualized needs of a resident diagnosed with [REDACTED].#82's expressions of distress/[MEDICAL CONDITION] ([NAME]D) thus preventing her from attaining or maintaining her highest practicable mental and psychosocial well-being. This was found for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #82. Facility census: 99. Findings included: a) Resident #82 Review of the medical record on 08/22/18, revealed Resident #82 was admitted to the facility in (MONTH) (YEAR) with a [DIAGNOSES REDACTED]. Her annual minimum data set assessment with an assessment reference date of 08/09/18 includes the following Diagnoses: [REDACTED]. Resident #82 experienced two or more falls without injury since the previous assessment and is receiving the following daily meds: antipsychotic, antianxiety and antidepressant. Random observations on 08/20/18 and 08/21/18 found Resident #82 cleaning her room, making her bed and repeatedly folding items as she verbalized complaints about the cleaning practices of the staff. The care plan with a revision date of 08/21/18 lists the following focus: --(Name) has a behavior problem r/t Compulsiveness. The goal states: (Name) will have fewer episodes of deliberately getting self on floor to clean before bed by review date. Interventions note the following (typed as written): Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Establish limits for inappropriate behaviors resident has [NAME]D behaviors about cleaning. she often gets on the floor deliberately to clean. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternative location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential cause. --(Name) is at risk for falls r/t impaired mobility, poor safety awareness, impaired cognition, use of medications with fall related side effects, history of falls. The goal is: (Name) will not sustain serious injury through the review date. Interventions: Encourage participation in activities that promote exercise, physical activity for strengthening and improving mobility. Ensure call light is within reach and encourage resident to use it for assistance as needed. 2 non-skid strips in front of residents toilet to prevent sliding. Ensure resident is wearing appropriate footwear when transferring or mobilizing in w/c (wheelchair). Provide a safe environment with: code alert to w/c at all times, non-skid strips at bedside bed, raised mattress, and bed/chair alarms. After reviewing Resident #82's care plan on 08/22/18 at 10:30 AM, the Director of Nursing agreed the goals are non-measurable and the care plan lacks person-centered non-pharmacological interventions to address Resident #82's compulsive actions.",2020-09-01
419,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2018-08-24,761,D,0,1,7DWR11,"Based on observation and staff interview, the facility failed to date medications when opened and put into use for one (1) of two (2) medication carts observed. Insulin and Sodium Chloride tablets were not dated when opened. Facility census: 99. The findings include: During observation of the medication cart, on the West wing of the facility, on 08/23/18, at 01:25 PM, two medications were found not be dated when opened and put into use. 1) A bottle of Sodium Chloride tablets was opened but there was no date of when the medication was opened and put into use. An interview with LPN#112, on 08/23/18, at 01:25 PM, confirmed there was no date on the bottle and the bottle was opened and in use. 2) An injectable insulin pen for Resident #85 was observed to have no date when opened . An interview with LPN#112, on 08/23/18, at 01:25 PM, verified the insulin pen had not been dated when put into use. LPN#112 further stated it was opened on 8/15 and proceeded to date the insulin pen at this time. An interview with LPN#31, on 08/23/18, at 2:40 PM, revealed that it is the requirement that when a new medication is opened, it has to be labeled and dated when it is opened. When I train someone on the cart, that is how I train them.",2020-09-01
420,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2018-08-24,804,E,0,1,7DWR11,"Based on observation, staff interview, and resident council minutes, the facility failed to resolve issues regarding complaints of food taste and temperature, as well as timeliness of food service. This practice has the potential to affect more than a limited number of residents who receive food from this central location. Facility census: 99. Findings included: a) During lunch meal observations it was found that residents did sit in the dining room for an extended period of time while meals were being served. Residents in confidential interviews expressed how long the meal was taking and wondering where the food was going to be served. Those that ate in there rooms were also affected as carts with food were delivered well after the identified time frames for meal service. When this was brought to the administrator and food service director's attention, it was found the designated time frames given to surveyors was not the times that were on the procedures given to surveyors. The adminsitrator then did revise the prodecure to coincide with the practice currently being used. Resident council minutes documentation on monthly meeting minutes since (MONTH) showed the residents expressed concern food issues. In the confidential meeting held with surveyors on 08/21/18 at 11:00 a.m. residents expressed there were problems with food taste and temperatures.",2020-09-01
421,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2018-08-24,842,D,0,1,7DWR11,"Based on medical record review and staff interview, the facility failed to maintain a complete and accurate medical record for each resident. Resident #82's influenza consent is incomplete and lacks a date consent was obtained. This was true for one (1) of five (5) residents reviewed for influenza vaccines. Resident identifier: #82. Facility census: 99. Findings included: a) Resident #82 Review of the medical record on 08/22/18 at 9:30 AM, revealed Resident #82 received the influenza vaccine on 10/19/17. An undated influenza informed consent form identifies a phone consent from the Resident's daughter. The influenza consent form was reviewed with the Director of Nursing (DON) on 08/22/18 at 10:30 AM. The DON acknowledged the influenza consent form lacked the date the consent was obtained form Resident #82's daughter.",2020-09-01
422,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2018-08-24,880,F,0,1,7DWR11,"**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 Prevention and Control Program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infections. Staff failed to perform proper hand hygiene and contaminated a multi-dose eye drop bottle during medication administration. Infection control policies were not reviewed annually and monthly tracking and trending logs only list residents receiving antibiotics. This practice has the potential to affect all residents residing in the facility. Facility census: 99. Findings included: a) Hand washing During observations of medication administration on 08/22/18 at 7:42 AM, Licensed Practical Nurse (LPN) #108 washed her hands for three seconds / to the count of three after passing medications to Resident #60. LPN #108 proceeded to pass meds to Resident #31 and again washed her hands for three seconds. LPN #108 retrieved an additional pill ([MEDICATION NAME]) for Resident #31 and failed to rewash / sanitize her hands prior to administered medications to Resident #55. LPN #108 reported hands should be washed for a minimum of 20 seconds during an interview on 08/22/18 at 1:12 PM. The facility hand washing policy received from the Director of Nursing (DON) on 08/22/18 states under the section titled Procedure for Hand Hygiene Rub hands vigorously for at least 20 seconds . b) Tracking and Trending Review of the facility tracking and trending logs from 03/01/18 through 08/17/18, on 08/23/18 revealed every resident listed was on an antibiotic. There were no records tracking residents with symptoms and not requiring antibiotics. The tracking and trending logs were reviewed with Infection Control Nurse / Registered Nurse (RN) #81 during an interview on 08/23/18 at 8:30 AM. RN #81 agreed the log only contains resident's receiving antibiotics. c) Eye drops During medication administration observation, on 08/22/18, at 07:50 AM, resident #17 was being administered [MEDICATION NAME] eye drops, 1 drop to each eye. LPN #2 washed her hands and donned gloves before administering the eye drops. LPN#2 used her gloved left hand to hold down the lower eye lid for the administration of the eye drops. When finished, LPN#2 used her contaminated gloved hand to replace the lid on the eye drops and place them in the box. LPN#2 then picked up the box that she had touched with the contaminated gloved hand and replaced it in the medication cart. An interview with LPN#2 on 8/22/18, at 8:25 am, verified the nurse had used a contaminated hand to replace the lid on the eye drops and then replaced the container back into the box. LPN#2 stated I agree, I contaminated the container with my glove. d) Policy review Review of the facility infection control policies on 08/23/18 at 8:00 AM revealed policies were not reviewed annually. The policy titled: Infection Prevention Program was last revised on 04/10/17. The Antibiotic Stewardship Plan policy and the Antibiotic Stewardship Overview policy were revised 04/20/17 and noted to be effective on 05/01/17. The Director of Nursing confirmed the above policies were not reviewed annually during an interview on 08/23/18. No updated policies were received prior to exit.",2020-09-01
423,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2018-08-24,881,F,0,1,7DWR11,"Based on medical record review, staff interview and policy review, the facility's Infection Prevention Control Program failed to develop an antibiotic stewardship program that promotes the appropriate use of antibiotics. Staff were unfamiliar with the term antibiotic stewardship. Assessment tools were not utilized prior to the prescribing and administration of antibiotics. This practice has the potential to affect all residents residing in the facility. Resident identifiers: #66 and #46. Facility census: 99. Findings included: a) Antibiotic Stewardship program On 08/23/18, Licensed Practical Nurse (LPN) #100 reported she was unfamiliar with the term antibiotic stewardship. LPN #100 stated there are no assessment tools such as the McGeer's criteria for staff to utilize when assessing a resident for infection, prior to initiation of antibiotics. The nurse gathers the symptoms and contacts the physician for orders. LPN #100 reported she is unaware of any information utilized to educate the residents and/or families in regards to reducing the use of antibiotics. During an interview on 08/23/18 at 8:30 AM, the Infection Control Nurse / Registered Nurse (RN) #81 reported she utilizes the McGeer's criteria as an infection assessment tool after antibiotics are initiated. The facility does not utilize an infection assessment tool while assessing a resident for a possible infection prior to contacting the physician and/or while working with the physician in assessing the resident for any type of infection. The facility policy titled Minimum Criteria for Antibiotic Use states under the policy section: .The facility will use the McGeer's Criteria for Long-Term Care as a foundation for reporting infections.",2020-09-01
424,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2018-08-24,921,D,0,1,7DWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure the resident's environment was safe for one (1) of twenty-nine (29) rooms observed on the East unit. The baseboard heater in room [ROOM NUMBER] East was rusty from water damage. Facility census: 99. Findings included: a) room [ROOM NUMBER] East On 08/23/18, at , 08:23 AM an area of rust was observed on the baseboard heater in room [ROOM NUMBER] East which is occupied by four residents who utilize a wheelchair for mobility. The baseboard heater is located near the resident's sink with the area of rust being at the closest end to the sink. There was also damage to the front of the baseboard heater unit. The cover of the baseboard heater was bowed inward. An interview with Maintenance Supervisor #16, on 08/23/18, at 08:40 AM, revealed the rust was caused from water from the sink spilling onto the heating unit, and the damage to the front of the baseboard heater was caused by wheelchairs scraping the unit. Further investigation revealed the baseboard heater in room [ROOM NUMBER] East did not have a ground fault circuit interrupter. Further interview with Maintenance Supervisor #16, on 08/23/18, at 08:40 AM, revealed that the facility would update the breaker before fall. Further interview with Maintenance Supervisor #16, on 08/23/18, at 09:20 AM, revealed they have decided to remove the unit from use.",2020-09-01
425,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2019-09-12,558,E,0,1,EQG311,"Based on observation, resident interview and staff interview; the facility failed to make reasonable accommodations for each resident's needs. Residents #56, #79, #2, #46, and #85; were unable to reach the cord for the overbed light. Additionally, Resident #46's wheelchair was unable to fit through the bathroom door; which interfered in her ability to use the toilet. These observation were random opportunities of discovery. Resident identifiers: #56, #79, #2, #46 and #85. Facility census: 97. Findings included: a) Resident #56 Observation on 09/09/19 at 1:30 pm, found the residents cord to the overbed light's cord was short and Resident #56 was unable to reach the cord to turn on and off the overbed light if needed and/or want the light on or off. b) Resident #79 Observation on 09/09/19 at 3:30 pm, found the residents cord to the overbed light's cord was short and Resident #79 was unable to reach the cord to turn on and off the overbed light if needed and/or want the light on or off. He was observed ambulating in the room; but still not able to reach the cord. c) Resident #2 Observation and interview on, 09/09/19 at 3:30 pm, found the residents cord to the overbed light's cord was short and Resident #2 was unable to reach the cord to turn on and off the overbed light if needed and/or want the light on or off. When asked if he could reach the over the bed light cord, he said, no. d) Resident #46 Observation and interview, on 09/09/19 at 4:15 pm, found the residents was unable to reach her cord to the overbed light due to it being too short and Resident #46 also voiced to me she could not use the toilet in her bathroom due to her wheelchair was too wide to go through the door. She further expressed she had to use the bedside commode and would really like to use the toilet in her room. Interview with the Nursing Home Administrator (NHA), on 09/12/19 at 10:15 am, informed her Residents #56, #79, #2, and #46 was unable to reach the cords to the over the bed lights and additionally, Resident #46's wheelchair was too big to fit through the bathroom door and she would like to use the toilet in her bathroom. No further information provided. Director of Nursing (DON) also informed of the findings. . e) Resident #85 During the initial tour of the facility, on 09/09/12 at 2:52 PM, observed Resident #85 had two (2) clear trash bags tied together which were attached to the overbed light pull. When Resident #85 was asked what the trash bags were for she stated that is so I can turn on my overbed light. An interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DoN) on 09/12/19 at 8:26 AM both confirmed this was not an appropriate pull cord for the overbed light.",2020-09-01
426,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2019-09-12,578,D,0,1,EQG311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to properly record a resident's advanced directives in the medical record regarding specifying the length of a trial period of intravenous fluids (IVFs). This was true for one (1) of one (1) sampled residents reviewed for the care area of advanced directives. This practice had the potential to affect a limited number of residents. Resident identifier: #41. Facility census: 97. Findings included: a) Resident #41 A review of Resident (R#41)'s medical record, on 09/09/19 at 4:11 PM, revealed the Physician order [REDACTED].#41 POST indicates the resident is a 'Do Not Resuscitate (DNR)'. Review of the R#41's POST revealed the trial period for IV (Intravenous) fluids was not designated in section C. Section C read, IV fluids for trial period no longer than ___. Section C was left blank and did not instruct for how long the trial period should last. On 09/11/19 at 10:51 AM an interview with the Director of Nursing (DON) revealed the DON confirmed R#41's POST should have been filled out in its entirety. The DON agreed Section C of R#41's POST should have designated how long the trial period for IV fluids should last.",2020-09-01
427,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2019-09-12,580,E,0,1,EQG311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and family interview; the facility failed to notify the resident representative and/or the physician when changes in their condition occurred. This was true for one (1) of one (1) resident reviewed for the care area of notification of change and a random opportunity for discovery. Resident #46'sphysician was not notified when blood sugar was greater than 500 as directed by the physician-ordered parameters. Resident #2's physician and registered dietician was not notified timely of weight loss. Resident #41's family was not notified concerning a fall and additionally, Resident #41's physician was not notified of the resident's abnormal blood pressures. Resident identifiers: #46, #2 and #41. Facility census: 97. Findings include: a) Resident #46 Review of Resident #46's medical record found she was readmitted on [DATE] after having an abdominal hysterectomy. Review of the physician orders [REDACTED]. No sliding scale coverage. Notify the physician if blood sugar is less than 40 or greater than 500. Review of (MONTH) and (MONTH) 2019's Medication Administration Record [REDACTED]. Nurse's notes reviewed and no indication the nurse notified the physician as directed by the physician-ordered parameters. Interview with the Director of Nursing (DON) on 09/12/19 at 11:15 am; review of Resident #46's medical records confirmed the physician was not notified on 07/18/19. b) Resident #2 Review of Resident #2's medical records found the electronic weights found the following: --01/01/19- weight 110.6 pounds (lbs.) --02/01/19- weight 112.4 lbs. --03/05/19- weight 109.8 lbs. --04/05/19- weight 105.8 lbs. --05/09/19- weight 101.4 lbs. --06/07/19- weight 98.6 lbs. --07/15/19- weight 99.9 lbs. --08/09/19- weight at 12:05 am 98 lbs.- {greater than 10% change in weight over 180 day (s); Comparison weight 02/01/19. 112.4 lbs.; which is a 12.8% or a loss of 14.4 lbs.} --08/09/19- weight at 3:18 pm 97 lbs. {greater than 10% change in weight over 180 day (s); Comparison weight 02/01/19. 112.4 lbs.; which is a 13.7% or a loss of 15.4 lbs.} --09/03/19- weight 95.2 lbs. {greater than 10% change in weight over 180 day (s); Comparison weight 03/05/19. 109.8 lbs.; which is a 13.3% or a loss of 14.6 lbs.} Review of Resident #2's nurses note found the physician and registered dietician was notified of the weight loss on 08/19/19. Interview with the DON on 09/12/19 at 11:30 am, after review of the medical records, she confirmed the physician and registered dietician was not notified of the weight loss noted on 08/09/19; until ten (10) days later on 08/19/19 at 12:54 pm. She agreed this was not timely notification of the resident weight loss. c) Resident (R#41) 1. Failed to notify Medical Power of Attorney (MPOA) of a fall. A family interview, on 09/09/19 at 12:21 PM, revealed the resident's Medical Power of Attorney (MPOA) was not always notified when the resident has had a fall. The MPOA said that she was told by the resident's roommate her mother had fallen several months ago. The MPOA stated, No one at the facility told her only the roommate, none of the staff. On 09/10/19 at 01:26 PM reviewed of the incident log revealed R#41had fallen several times, including 05/12/19. Review of records revealed a nurse was summoned to the resident's room by the daughter of the roommate's visitor, on 05/12/19 to help R#41 because she had fallen. The record showed the physician was notified of the fall, however there was no documentation showing that the MPOA was notified. 2. Facility failed to notify the physician of a change in R#41's blood pressure reading Review of records, on 09/10/19 at 4:02 PM, revealed a progress note dated 09/04/19 stating the MPOA was in and expressed concerns of her mother being sleepy. R#41's blood sugars and blood pressure (BP) was checked. Blood sugars was 155 and blood pressure was high at 178/106. The physician was notified, and new orders were given Check BP BID FOR 2 WEEKS R/T ELEVATED BP (check blood pressure two times a day for two weeks related to elevated blood pressure) Review of the blood pressures being monitored, on 09/11/19 01:00 PM, revealed a reading taken on 09/10/2019 at 8:20 AM of -10.0% change from baseline value at a reading of 145/68. There was no documentation or evidence the physician was notified of this change. On 09/11/19 at 01:30 PM an interview with the Director of Nursing (DoN) confirmed there was no evidence the physician was notified of the blood pressure reading taken on 09/10/2019 at 8:20 AM of -10.0% change from baseline. The DoN stated her expectation of the nursing staff would be for the nurses to notify the physician of the change in blood pressure on 09/10/2019 and for the nurses to clarify the order to include specific parameters.",2020-09-01
428,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2019-09-12,583,D,0,1,EQG311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure personal privacy during incontinence care. This was true for one (1) of one (1) sampled residents reviewed for the care area of incontinence. This practice had the potential to affect a limited number of residents. Resident identifier: #81. Facility census: 97. Findings included: Review of Resident (R#81)'s recent thirty (30) day minimum data set (MDS) with an assessment reference date (ARD) 08/24/19 revealed the resident's Brief Interview for Mental Status (BIMS) with a score of three (03) indicating resident is cognitively severely impaired. The resident is dependent for bathing and needs extensive assistance with all other activities of daily living. Resident #81 is frequently incontinent of bladder and bowel. Some pertinent [DIAGNOSES REDACTED]. Observations of Nurse Aid (NA#118) providing incontinence care for R#81 on 09/12/19 at 08:59 AM, revealed NA#118 failed to maintain R#81 personal privacy. NA#118 forgot to place a plastic bag to dispose of used soiled supplies within the area the NA was working. When NA#118 went to get the plastic bag she opened the privacy curtain and forgot to close the curtain back. The resident was fully exposed if anyone should have open the resident's room door while she was being cleaned and her brief was being changed. NA#118 confirmed she compromised the resident's privacy while providing incontinence care when she forgot to pull the privacy curtain back to block the view from the doorway.",2020-09-01
429,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2019-09-12,641,E,0,1,EQG311,"**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 Sets (MDS)accurately reflected the resident's status. This was true for four (5) of twenty-three (23) sampled resident's MDSs reviewed during the Long-Term Survey Process (LTCSP). Resident #56's MDS was inaccurate in the area of falls in the facility. Resident #39's MDS was in the area of pressure ulcers. Resident #60's was inaccurate in area of nutritional/weight loss status. Residents #22's MDS was inaccurate in area of medication. Resident's identifiers: #56, #39, #60, and #22. Facility census: 97. Findings included: a) Resident #56 Review of Resident #56's significant change MDS with Assessment reference date (ARD) of 07/17/19, found under section J related to falls. The MDS question is J1800- Has the resident had any falls since admission/readmission or the prior assessment ( quarterly MDS with ARD of 04/18/19), whichever is more recent? Answer on MDS with ARD of 07/17/19 was, No. Review of the resident falls found Resident #56 had fell on [DATE] at 6:30 pm. Interview with Employee #109, Registered Nurse (RN) MDS coordinator, on 09/11/19 at 2:10 pm, confirmed the MDS with ARD of 07/17/19 was inaccurate in area of falls. She immediately corrected and resubmitted the corrected MDS. b) Resident #39 Review of Resident #39's 30 day MDS with Assessment reference date (ARD) of 07/11/19, found under section M related to pressure ulcers. The MDS question is M0100- Check all that apply: a) resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device, b) formal assessment instrument/tool (e.g. Braden, Norton, or other), c) clinical assessment, z) none of above. Checked was c. only. Further review of section M pressure ulcers, found resident had a stage 2 pressure ulcer and was present on admission. Interview with Employee #109, Registered Nurse (RN) MDS coordinator, on 09/11/19 at 3:10 pm, confirmed the MDS with ARD of 07/11/19 was inaccurate in area of pressure ulcers. She immediately corrected and resubmitted the corrected MDS with M100- a, b, and c were all checked. c) Resident #22 During a review of the medical record for Resident #22 during the survey, revealed Resident #22 Minimum Data Set (MDS) with Assessment Reference Dates (ARDs) of 05/23/19, 05/30/19, 6/18/19, 06/25/19, 07/09/19 and 08/01/19 Section N coded as having received insulin. Resident #22 was ordered [MEDICATION NAME] (hormone to help body secrete own insulin) and not insulin. The MDS Coordinator confirmed, on 09/11/10 at 11:44 AM, that the [MEDICATION NAME] was coded as insulin which made Section Nof the MDS inaccurate. The MDS Coordinator stated that Section N would be corrected immediately. d) Resident #60 - Nutritional Status On 09/11/19 at 9:52 AM Resident #60's significant change minimum data set (MDS) assessment with an assessment reference date (ARD) of 07/23/19 was reviewed. Resident #60's weight in section K, the nutritional section of the MDS, was coded as 150 pounds. Per MDS section K instructions, weight should be based on the most recent measurement in the last 30 days. A review of Resident #60's weight measurements during the survey found no weight measurement within 30 days of the ARD of 07/23/19. On 09/11/19 at 10:27 AM Resident Assessment Coordinator Registered Nurse (RAC RN) #109 stated that Resident #60's 06/07/19 weight of 149.6 pounds had been used to code section K. When asked why a weight over 30 days old was used to code the MDS, RAC RN #109 stated she needed to read the resident assessment instrument (RAI) manual before responding. On 09/11/19 at 10:42 AM RAC RN agreed that the wrong weight was used to code Resident #60's section K. On 09/11/19 at 2:59 PM the above information was discussed with the facility's Administrator. No further information was provided prior to exit.",2020-09-01
430,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2019-09-12,657,E,0,1,EQG311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to revise the comprehensive care plan for 5 out of 23 sample residents reviewed in the annual long-term care survey process (LTCSP). This practice had the potential to affect more than a limited number of residents. Resident identifiers: #35, #39, #41, #60 and #82. Facility census: 97. Findings included: a) Resident #41 Resident (R#41)'s care plan was not revised to include restorative nursing services. An interview with R#41's Medical Power of Attorney (MPOA), on 09/09/19 at 12:12 PM, revealed concerns about the resident spending too much time in a wheelchair and not being walked by staff. The MPOA states she visits frequently almost daily and rarely sees her mother being walked by staff. The MPOA said she was told there is no restorative program, but they said they were going to start it up again soon. On 09/11/19 at 03:02 PM, an interview with Nurse Aid (NA#105) assigned to R#41 revealed NA#105 did not walk R#41 because the resident has had falls recently and NA#105 said she is afraid to walk R#41 for fear she would fall. NA#105 also stated the resident would need a walker and she did not have one in her room. An interview with Registered Nurse (RN#109), on 09/11/19 at 03:56 PM, revealed the resident was currently on restorative nursing services for ambulation. RN#109 was responsible for the restorative nursing program and stated the resident was on the 'Walk to Dine' program. RN#109 explained the NAs on the floor are responsible for the resident's 'Walk to Dine' program. RN#109 said the NAs would walk the resident to lunch and dinner 6 days a week using a front wheel walker which typically is kept in the resident's room. RN#109 stated the resident was discharged from physical therapy on 05/17/19 and then was ordered restorative services at that time. On 09/12/19 at 11:51 AM, an interview with Nurse Aid (NA#19), revealed NA#19 occasionally walks R#41. NA#19 stated, I walk her with a gait belt. We walk her if we have time, and that is not every day. When asked if the resident was on any restorative nursing programs, NA#19 said she was not aware of her being on any programs. Observations on 09/12/19 at 11:54 AM revealed R#41 sitting in her wheelchair at a dining room table with her daughter waiting on lunch. Her daughter/MPOA stated I bring her to the dining room in her wheelchair almost every day for lunch no one has ever told me about a walk to dine program and none of the NAs has ever came to her room to get her to walk her to lunch. An interview with the resident assessment coordinator RN#103 responsible for developing and revising care plans, on 09/12/19 at 12:11 PM, confirmed restorative services were ordered for R#41. RN#103 stated the care plan should have been revised to include restorative and was not. R#41's quarterly care plan meeting was not held as required. An interview with R#41's Medical Power of Attorney (MPOA), on 09/09/19 at 12:04 PM, revealed the MPOA is not always invited to all of R#41's care plan meetings. The MPOA stated it has been longer than 3 months since she attended a care plan meeting for her mother. Review of records, on 09/10/19 at 03:14 PM, revealed the Resident's (R#41) Initial Care Plan conference was held on Tuesday 11/20/18 at 2:15 PM with resident's daughter in attendance. Records showed a quarterly care plan conference was also held on 2/26/19. On 09/11/19 at 10:00 AM, an interview with social worker (SW#79) revealed she tracked residents scheduled care plan meetings and calendars in a notebook. SW#79 explained how she uses her notebook as her system of tracking and ensuring care plan meetings occur quarterly as required. SW#79 stated she keeps up with care plan meetings that are to be held and hand writes changes on her scheduling sheets in her notebook. When asked to see when R#41's care plan meetings had been scheduled, SW#79 looked through her notebook twice and could not find R#41 in her notebook other than 11/20/18 and 2/26/19. Review of a social work note dated 03/01/19, revealed a quarterly care plan conference was held on 2/26/19. SW#79 stated the next date for a meeting must have been in another book and she would look and get back to this surveyor. SW#79 informed this surveyor, on 09/11/19 at 02:55 PM, that a quarterly care plan meeting for R#41 was missed. SW#79 said they did not have one as they should have, but they will make it up. c) Resident #35 A review of the care plan and physician orders [REDACTED]. The care plan stated Monitor/document/report to MD PRN (as needed) the following s/sx (signs/symptoms): [MEDICAL CONDITION]; weight gain of over 2 lbs a day; . dated 11/09/17. The Assistant Director of Nursing ( ADON) confirmed the care plan had not been revised/updated to reflect current physician orders. d) Resident #39's Nutrition Care Plan On 09/10/19 at 12:18 PM Resident #39 was observed eating lunch. She appeared thin and frail upon observation. A review of Resident #39's weight records during the survey found that she had lost 29.8 pounds since her admission to the facility on [DATE]. Per weight records, on 06/14/19 Resident #39 weighed 100 pounds and on 08/09/19 she weighed 70.2 pounds. On 09/11/19 at 11:30 AM Regional Director of Clinical Operations (RDCO) #64 provided a hospital speech evaluation dated 05/24/19. Per the evaluation, Resident #39 weighed 80 pounds at the time of the assessment. RDCO #64 agreed that Resident #39 had lost weight, but also stated she believed Resident #39's admission weight to be inaccurate. A review of Resident #39's nutrition care plan during the survey found the following focus, last revised on 06/14/19: (Resident's Name) has potential nutritional problem r/t (related to) Severe Protein Calorie Malnutrition, Failure to Thrive, multiple vitamin deficiencies. The goal associated with the focus was last revised on 06/28/19 and stated: (Resident's Name) will maintain adequate nutritional status as evidenced by maintaining weight within 5% (percent) of baseline, no s/sx (signs/symptoms) of malnutrition, and consuming at least 76-100% of all meals daily through review date. On 09/11/19 at 12:29 PM Culinary Director (CD) #123 was interviewed regarding Resident #39's care plan. CD #123 agreed that, due to her weight loss since admission, Resident #39 had an actual nutritional problem rather than a potential nutritional problem and Resident #39's goal for no significant weight loss was no longer appropriate. CD #123 added that the facility's Registered Dietitian (RD) would update the care plan to reflect Resident #39's weight change. The above information was discussed with the facility's Administrator on 09/11/19 at 2:59 PM. No further information was provided prior to exit. e) Resident #60's Nutrition Care Plan On 09/10/19 at 12:21 PM Resident #60 was observed eating lunch. Resident #60 appeared thin and frail during the observation. A review of Resident #60's weight records during the survey found that Resident #60 had experienced a significant weight loss of 18 percent of his body weight in three (3) months. On 05/08/19 Resident #60 weighed 156.2# and on 08/09/19 he weighed 128.4 pounds. A review of Resident #60's nutrition care plan during the survey found the following focus, last revised on 07/05/19: (Resident's Name) has a potential nutritional problem r/t (related to) nursing home placement, HX (history) [MEDICAL CONDITION]. The goal associated with the focus, last revised on 08/02/19, stated: (Resident's Name) will maintain adequate nutritional status as evidenced by maintaining weight within 5% (percent) of baseline, no s/sx (signs/symptoms) of malnutrition, and consuming at least 76-100% of all meals daily through review date. On 09/11/19 at 12:29 PM Culinary Director (CD) #123 was interviewed regarding Resident #60's care plan. CD #123 agreed that, due to his significant weight loss, Resident #60 had an actual nutritional problem rather than a potential nutritional problem and Resident #60's goal for no significant weight loss had not been revised to reflect Resident #60's significant weight loss over three (3) months. CD #123 added that the facility's Registered Dietitian (RD) would update the care plan to reflect Resident #60's weight change. The above information was discussed with the facility's Administrator on 09/11/19 at 2:59 PM. No further information was provided prior to exit. f) Resident #82's Care Conference During an interview on 09/10/19 at 8:14 AM Resident #82 stated that she wanted to attend her care conferences but could not because they were scheduled for days and times during which she was receiving [MEDICAL TREATMENT] treatments. Resident #82 stated that on her [MEDICAL TREATMENT] days she was out of the facility from approximately 11:00 AM to 5:00 PM. A review of Resident #82's physician's orders [REDACTED].#82 received [MEDICAL TREATMENT] treatments each Monday, Wednesday, and Friday. The order was dated 04/20/19. Record review during the survey found a Social Services Note dated 06/13/19 stating, Resident's care plan conference is scheduled for 6/19/19 at 2:00 pm. Resident was notified in person on 6/13/19. 06/19/19 was a Wednesday, meaning that Resident #82 was scheduled to receive a [MEDICAL TREATMENT] treatment that day. During the survey, a review of Resident #60's Plan of Care Note dated 06/20/19 and care conference signature sheet dated 06/19/19 confirmed that Resident #60 had not attended her care conference on 06/19/19. On 09/10/19 at 3:06 PM Social Worker (SW) #79 agreed that Resident #82's care conference had been scheduled for a [MEDICAL TREATMENT] day when Resident #82 could not attend. The above information was discussed with the facility's Administrator on 09/10/19 at 3:53 PM. She stated she would speak to SW #79 about it.",2020-09-01
431,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2019-09-12,684,E,0,1,EQG311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, observation and family 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. This was true for three (3) of twenty-three (23) residents reviewed. For Resident #56 the facility failed to follow up on resident's right hand and arm weakness. Resident #46 failed to provide her with incisional care after surgery and failed to follow physician orders [REDACTED].#41the facility failed to follow physician orders [REDACTED].#56, #46, and #41. Facility census: 97. Findings include: a) Resident #56 Medical record review for Resident #56, found a progress note written on 07/26/19 at 2:00 am which read: Reported from evening shift that resident's mother reported resident changes. Assessed patient and noted right hand and arm weakness. No other deficits noted at this time. Fax sent to doctor. No further notes found in reference of the resident's right hand and arm weakness. On 09/12/19 at 11: am. the Director of Nursing (DON) was asked about whether physician had responded to the fax from 07/26/19, concerning Resident #56's right arm and hand weakness. At 09/12/19 at 11:45 am, I was provided a fax concerning Resident #56's right arm and hand weakness. This fax was returned to the facility on [DATE] at 4:33 am with instructions from the physician to do neurological checks every shift for seventy-two (72) hours. DON confirmed at this time this was not completed as doctor requested. No further information provided. b) Resident #46 b.1.) Review of Resident #46's medical record, found on 01/31/19 the resident was readmitted after having an abdominal hysterectomy. Discharge instructions were to shower daily and provide wound care while in the shower with cleansing the area with warm soapy water. Use white, unscented soap like Dove or Dial. Pat the wound dry. Keep the wound clean, dry, and exposed to air. Review of readmission orders [REDACTED]. Use white, unscented soap like Dove or Dial. Pat the wound dry. Keep the wound clean, dry, and exposed to air. Review of Resident #46's shower record for (MONTH) 2019 found Resident #46 received a shower on 02/07/19 and was documented two (2) times on 02/11/19 and 02/21/19. No further documentation could be found. On 09/11/19 at 2:05 pm, the DON was asked if Resident #46 had received incisional care as directed in the discharge summary on 01/31/19. She confirmed there was not documentation the resident was offered and/or received the wound care as directed on the discharge summary. b 2.) On 02/15/19, Resident #46 had a follow-up appointment with the surgeon and was sent to the emergency room (ER) at local hospital from the doctor's appointment prior to returning to the facility. On 02/15/19, Resident #46 had a new order for [MEDICATION NAME] 875-125 milligrams (mg) by mouth twice daily for treatment of [REDACTED]. To be started on 02/15/19 at 5:00 pm and to end on 02/22/19 at 9:00 am. Review of the Medication Administration Record [REDACTED]. No information could be located to determine why Resident #46 received the [MEDICATION NAME] as ordered. On 09/12/19 at 11:45 am, Resident #46's medical records were reviewed with the DON and she confirmed the resident only received six (6) of the fourteen (14) doses prescribed. She also confirmed the reason the resident did not receive her antibiotic could be located. b. 3.) Resident #46 was ordered on [DATE] for [MEDICATION NAME] one 1 gram (gm) intramuscularly (IM) at 10:00 pm for five (5) days for the treatment of [REDACTED]. Review of the MAR for (MONTH) 2019, found the resident only received four (4) doses of the five (5) doses ordered. Review of the (MONTH) 2019 MAR indicated [REDACTED]. c) Resident #41 The facility failed to follow physician's orders [REDACTED].#41)'s restorative program An interview with R#41's Medical Power of Attorney (MPOA), on 09/09/19 at 12:12 PM, revealed concerns about the resident spending too much time in a wheelchair and not being walked by staff. The MPOA states she visits frequently almost daily and rarely sees her mother being walked by staff. The MPOA said she was told there is no restorative program, but they said they were going to start it up again soon. On 09/11/19 at 03:02 PM, an interview with Nurse Aid (NA#105) assigned to R#41 revealed NA#105 did not walk R#41 because the resident has had falls recently and NA#105 said she is afraid to walk R#41 for fear she would fall. NA#105 also stated the resident would need a walker and she did not have one in her room. Observation of resident's room revealed no walker currently in the resident's room. An interview with Registered Nurse (RN#109), on 09/11/19 at 03:56 PM, revealed the resident was currently on restorative nursing services for ambulation. RN#109 was responsible for the restorative nursing program and stated the resident was on the 'Walk to Dine' program. RN#109 explained the NAs on the floor are responsible for the resident's 'Walk to Dine' program. RN#109 said the NAs would walk the resident to lunch and dinner 6 days a week using a front wheel walker which typically is kept in the resident's room. RN#109 stated the resident was discharged from physical therapy on 05/17/19 and then was ordered restorative services at that time. On 09/12/19 at 11:51 AM, an interview with Nurse Aid (NA#19), revealed NA#19 occasionally walks R#41. NA#19 stated, I walk her with a gait belt. We walk her if we have time, and that is not every day. When asked if the resident was on any restorative nursing programs, NA#19 said she was not aware of her being on any programs. Observations on 09/12/19 at 11:54 AM revealed R#41 sitting in her wheelchair at a dining room table with her daughter waiting on lunch. Her daughter/MPOA stated I bring her to the dining room in her wheelchair almost every day for lunch no one has ever told me about a walk to dine program and none of the NAs has ever came to her room to get her to walk her to lunch. An interview with the resident assessment coordinator RN#103 responsible for developing and revising care plans, on 09/12/19 at 12:11 PM, confirmed restorative services were ordered for R#41. RN#103 stated the care plan should have been revised to include restorative and was not.",2020-09-01
432,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2019-09-12,689,D,0,1,EQG311,"Based on observation, staff interviews and resident interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible. Resident #3 was observed having a cigarette and lighter on his person. This practice was true for one (1) of two (2) residents who smoked. Resident identifier: #3. Facility census: 97. Findings included: a) Resident #3 Observed Resident #3 in the designated resident smoking area, on 09/10/19 at 11:32 AM, remove a cigarette and lighter from his person and begin smoking. Resident #3 put the lighter in his pocket. A review of the facility smoking policy and procedure during the survey found under Procedure 8. Facility staff will: a. Secure smoking materials in a locked area when not in use by the resident/patient for both independent and supervised smokers. 9. a. Smoking materials will be maintained by the facility staff and provided to the resident/patient on request. c. Smoking materials will be returned to the facility staff upon completion of smoking. An interview with Licensed Practical Nurse (LPN) #32 on 09/ 12/19 at 8:05 AM found that no smoking materials were locked up in the medication room for Resident #3. An interview conducted on 09/12/19 at 8:07 AM with Resident #3 found this resident stated that he had no cigarettes or lighter in his room. On 09/12 at 11:58 AM the Nursing Home Administrator (NHA) stated that she had interviewed Resident #3 and he had cigarettes and a lighter in his room. The NHA stated that the cigarettes and lighter were removed from Resident #3 room and reeducated the resident as to the policy and procedure regarding smoking materials.",2020-09-01
433,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2019-09-12,692,D,0,1,EQG311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review the facility failed to fully address the nutritional status of its residents when the facility's clinical team and Registered Dietitian failed to address weight change timely. This deficient practice was found for 2 out of 5 residents reviewed for the care area of nutrition. Resident identifiers: #60 and #39. Facility census: 97. Findings included: a) Resident #60 On 09/10/19 at 12:21 PM Resident #60 was observed eating lunch. Resident #60 appeared thin and frail during the observation. A review of Resident #60's weight records during the survey found that Resident #60 had experienced a significant weight loss of 18 percent of his body weight in three (3) months. On 05/08/19 Resident #60 weighed 156.2# and on 08/09/19 he weighed 128.4 pounds. During the survey, a review of the facility's weight policy, last reviewed on 05/29/19, found that, Weight loss concerns will be discussed at the weekly clinical meetings. However, no weekly clinical meeting notes were found for Resident #60. During the survey, all documentation regarding Resident #60's nutritional status was requested from administration. On 09/11/19 at 11:52 AM Regional Director of Clinical Operations (RDCO) #64 stated that there was no documentation and that the facility's Registered Dietitian (RD) had not addressed Resident #60's nutritional status since his weight change. b) Resident #39 On 09/10/19 at 12:18 PM Resident #39 was observed eating lunch. She appeared thin and frail upon observation. A review of Resident #39's weight records during the survey found that she had lost 29.8 pounds since her admission to the facility on [DATE]. Per weight records, on 06/14/19 Resident #39 weighed 100 pounds and on 08/09/19 she weighed 70.2 pounds. During the survey, a review of the facility's weight policy, last reviewed on 05/29/19, found that, Weight loss concerns will be discussed at the weekly clinical meetings. However, no weekly clinical meeting notes were found for Resident #39. During the survey, all documentation regarding Resident #39's nutritional status was requested from administration. On 09/11/19 at 11:52 AM Regional Director of Clinical Operations (RDCO) #64 stated that there was no documentation and that the facility's Registered Dietitian (RD) had not addressed Resident #39's nutritional status since her weight change.",2020-09-01
434,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2019-09-12,756,D,0,1,EQG311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to document the clinical rationale for not following pharmacy recommendations to discontinue a medication determined to be contraindicated for Resident #82. This deficient practice affected one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #82. Facility census: 97. Findings included: a) Resident #82 Resident #82 was selected by the Long-Term Care Survey Process (LTCSP) system for a review for unnecessary medications. A review of Resident #82's physician's orders [REDACTED].#82 received [MEDICAL TREATMENT] treatments three (3) times weekly. On 09/11/19 at 8:10 AM Resident #82's pharmacy consultation reports from (MONTH) 2019 were received and reviewed. Per the reports, the facility's Pharmacist recommended on 04/24/19 that the facility's Attending Physician discontinue Resident #82's Duloxetine HCl ([MEDICATION NAME]), a medication used to treat depression and anxiety, as Duloxetine HCl was contraindicated in residents receiving [MEDICAL TREATMENT]. The Attending Physician signed the report and provided written agreement with the recommendation on 05/02/19. Additionally, the Pharmacist's report stated, If this therapy is to continue, it is recommended that a) The prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual; and b) the facility interdisciplinary team ensures ongoing monitoring for adverse effects. A review of Resident #82's Medication Administration Record [REDACTED]. On 09/11/19 at 1:09 PM the facility's Director of Nursing (DoN) provided information regarding Resident #82's Duloxetine HCl indicating that the medication had been discontinued on 05/02/19 and restarted on 05/09/19 because the discontinuation failed. Documentation regarding the failure was requested from the DoN. On 09/11/19 at 1:27 PM Regional Director of Clinical Operations (RDCO) #64 stated that Resident #82 requested to restart the Duloxetine HCl. Documentation regarding the risks versus the benefits for restarting the medication was requested from RDCO #64 at that time. During a phone interview on 09/11/19 at 1:40 PM in the presence of RDCO #64, the Attending Physician acknowledged that he did not document the clinical rationale for restarting the Duloxetine HCl in Resident #82's medical record. No further information was provided prior to exit.",2020-09-01
435,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2019-09-12,791,D,0,1,EQG311,"Based on medical record review, observation, resident interview and staff interview, the facility failed to assist Resident #46 to obtain needed dental appointments for extraction of two (2) decayed and broken teeth. This was a random opportunity for discovery. Resident identifier: #46. Facility census: 79. Findings include: a) Resident #46 Observation and interview, on 09/09/19 at 4:15 pm, found the residents had few of her own teeth, which was decayed and broken .Resident #46 also voiced the dentist had seen her in the facility and had recommended to have two (2) of her teeth extracted. She could not recall the date of the exam but the staff had told her she would have to pay for it before they would make the appointment and she had told them she could not afford to have the teeth extracted. Review of Resident #46's medical records found on 02//22/19 the dentist had recommended she have two (2) teeth (#3 and #19 teeth) extracted. Tooth #19 was decayed and #3 tooth was broken at the gum level per the dentist consultation on 02/22/19. Nurse's notes for Resident #46 found a note written on 04/09/19 at 2:40 pm by Employee #132. registered nurse (RN) which read: (Dentist's name) made recommendations during last visit to have some teeth extracted. Spoke with the Business Office Manager (BOM) and since the resident has Medicaid insurance the procedure will have to be paid up front. Resident states She does not have the means to do this at this time. On 09/12/19 at 11:45 am, an interview with the Director of Nursing (DON), confirmed the facility had not assisted the resident in receiving needed dental care. She confirmed an appointment would be made as soon as possible.",2020-09-01
436,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2019-09-12,812,E,0,1,EQG311,"Based on observation and staff interview, the facility failed to maintain their main kitchen and resident nourishment rooms in a safe and sanitary manner when they failed to properly label and date foods and condiments and ensure the ice machine was clean. 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: 97 Findings included: a) Kitchen On 09/09/19 at 11:37 AM an initial tour of the facility's kitchen began with Regional Director of Clinical Operations (RDCO) #64 and Culinary Director (CD) #123. On 09/09/19 at 11:40 AM an open-to-air plastic bag containing corn bread was found in the reach-in freezer. RDCO #64 and CD #123 agreed that the cornbread needed to be discarded since it had been left open. On 09/09/19 at 11:46 AM residue was noted around the opening of the ice maker in the main kitchen. The residue was brown and rubbed off the ice maker with ease. At the time of the finding RDCO #64 confirmed the ice maker needed to be cleaned. On 09/09/19 at 11:50 AM, 27 pre-poured containers of what appeared to be maple syrup were found on a tray in the dry storage room with no label or date. At 11:51 AM two (2) 22-quart containers labeled flour and two (2) 22-quart containers labeled bread crumbs were found to have no date on them, though the containers held what appeared to be flour and bread crumbs. At 11:52 AM CD #123 confirmed the 27 syrup containers and four (4) 22-quart containers did not have dates. CD #123 then removed the syrup containers from the dry storage room and stated she would ensure the 22-quart containers were labeled. On 09/09/19 at 1:00 PM RDCO #64 was informed of the above findings. No further information was provided prior to exit. b) West Nourishment Room On 09/09/29 at 12:03 PM in the West nourishment room, a bottle of Gatorade in the refrigerator was found to have no date on it. CD #123 discarded the bottle upon discovery. On 09/09/19 at 1:00 PM RDCO #64 was informed of the above findings. No further information was provided prior to exit.",2020-09-01
437,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2019-09-12,880,E,0,1,EQG311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, CDC's (Centers for Disease Control and Prevention) Guidelines for infection control in Long term care facilities, and staff interview; the facility failed to maintain an effective infection control program. This is evident by the failure to maintain and complete infection control surveillance records in their entirety. This practice had the potential to affect more than a isolated number of residents. Facility census: 97. Findings included: a) Infection control program According to the CDC, surveillance is defined as the ongoing systematic collection, analysis, interpretation, and dissemination of data. A facility's infection prevention and control (IPC) program should use surveillance to identify infections and monitor performance of practices to reduce infection risks among residents, staff and visitors. Surveillance includes monitoring epidemiological significant organisms, such as multi-drug resident organisms (for example,[MEDICAL CONDITION], VRE, and CRE) or [DIAGNOSES REDACTED]icile among residents in the facility. The detailed data collection and analysis helps track and identify trends and opportunities for prevention. Review of the facility's infection surveillance, tracking and trending records kept in an infection control notebook, on 09/10/19 at 08:40 AM, revealed incomplete tracking information on the Infection Control Log. Review of the Infection Control Log showed the information to be documented included: Resident name; room number; admitted ; onset date; in house acquired (yes or no); site; infection related diagnosis; culture (yes or no); date of culture or chest X-ray; organism; antibiotic; isolated (yes or no); re-culture date; and date resolved. Review of the Infection Control Log, for (MONTH) 2019 East, revealed twenty-one (21) entries concerning residents. Three (3) entries did not document whether cultures were done with a yes or a no concerning one (1) wound and two (2) urinary tract infections. Out of the twenty-one (21) entries, only two (2) entries had the name of the organism. Only five (5) entries out of twenty-one (21) entries designated no for isolated, the rest were all blank and did not designate either yes or no as was the option. All twenty-one (21) entries did not have re-culture date or date resolved documented, they were left blank. Review of the Infection Control Log, for (MONTH) 2019 West, revealed twelve (12) entries concerning residents. Six (6) entries did not document whether cultures were done with a yes or a no. Out of the six (6) that did document a yes or a no whether cultures were done, only one (1) was marked yes but no date when the culture was done was recorded. Only one (1) organism was named. Only three (3) entries out of twelve (12) entries designated no for isolated, the rest were all blank. All twelve (12) entries did not have re-culture date or date resolved documented, they were left blank. Review of the Infection Control Log, for (MONTH) 2019 East, revealed twelve (12) entries concerning residents. Six (6) entries did not document whether cultures were done with a yes or a no. Out of the twelve (12) entries, only one (1) entry had the name of the organism. All twelve (12) entries did not have re-culture date or date resolved documented, they were left blank. Review of the Infection Control Log, for (MONTH) 2019 West, revealed eleven (11) entries concerning residents. Nine (9) entries did not document whether cultures were done with a yes or a no. Out of the eleven (11) entries, only two (2) entries had the name of the organism. All eleven (11) entries did not have re-culture date or date resolved documented, they were left blank. Interview with Registered Nurse (RN#113) responsible for the facility's Infection control program, on 09/12/19 at 10:56 AM, revealed that several different staff had been responsible for the position of overseeing the Infection control program during the past year. RN#113 stated not everyone did what they were supposed to do with surveillance and tracking. RN#113 stated she had recently started doing the infection control program and was aware key information was missing in the surveillance and tracking documentation. RN#113 confirmed some key information was not tracked, such as the name of an organism, or whether a culture was or was not done, or when it was resolved. RN#113 verified the infection control log was to be filled out in its entirety and it had not been. RN#113 agreed it was important to know what the organisms were when monitoring and tracking trends, and to document all pertinent information asked for on the infection control log.",2020-09-01
438,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2019-09-12,883,E,0,1,EQG311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, review of Centers for Disease Control (CDC) recommendations, review of the State Operation Manual Appendix P, and staff interview; the facility failed to determine and offer to residents or resident's representatives the opportunity for the resident to receive the pneumococcal vaccine in accordance with accepted guidelines (pneumococcal [MEDICATION NAME] vaccine (PPSV23) and/or pneumococcal conjugate vaccine (PCV13)). This was true for 2 of 5 residents reviewed for the care area of immunizations. This practice had the potential to affect more than a limited number of residents. Resident identifiers: Residents #81 and #37. Facility census: 97. Findings included: a) Resident (R#81) Review of Resident (R#81) records, on 09/12/19 at 12:17 PM, revealed an informed consent for Pneumococcal [MEDICATION NAME] vaccine (PPSV23) dated 11/14/16. The informed consent referenced and provided education concerning only PPSV23, with information on the vaccine name/route, indications, primary schedule, and contraindications. Review of R#81's medical records revealed no evidence or indication information concerning the PCV13 pneumococcal vaccine was ever provided nor was there any evidence PCV13 was ever offered to the resident or resident representative. The informed consent dated 11/14/16 showed the resident's representative refused PPSV23 for the resident. The record showed no reason was documented for the refusal. The facility had no record of pneumococcal vaccine history for R#81. This resident is over the age of 65. b) Resident (R#37) Review of Resident (R#37) records revealed an informed consent for Pneumococcal [MEDICATION NAME] vaccine (PPSV23) dated 05/08/13. The informed consent referenced and provided education concerning only PPSV23, with information on the vaccine name/route, indications, primary schedule, and contraindications. Review of R#37's medical records revealed no information on the PCV13 pneumococcal vaccine was ever provided nor was there any evidence PCV13 was ever offered to the resident or resident representative. The informed consent showed the resident's representative refused PPSV23 for the resident. The record showed no reason was documented for the refusal. The facility had no record of pneumococcal vaccine history for R#37. R#37 is over the age of 65. d) CDC / ACIP Recommendations The Advisory Committee on Immunization Practices (ACIP) currently recommends that a dose of PCV13 be followed by a dose of PPSV23 in all adults aged greater or equal to [AGE] years who have not previously received pneumococcal vaccine and in persons aged greater or equal to 2 years who are at high risk for pneumococcal disease because of underlying medical conditions . The recommended intervals between PCV13 and PPSV23 given in series differ by age and risk group and the order in which the two vaccines are given. e) A review of the policy and procedure IC-1019-00 dated 10/01/17, notes Residents who refuse the vaccination may receive the vaccinations at a later date if they reconsider. and the pneumonia vaccine are considered part of the routine vaccine schedule for those over the age of 65 but both should not be given at same time. If the resident desires to receive both, PCV 13 should be administered first with PPSV23 to follow in 11 months. f) Review of the facility's current consent/declination for Pneumonia vaccine, Form#1117-01, revised 03/01/17 revealed under the Consent section, I/resident representative have received education including but not limited to the following, prior to receiving pneumonia vaccination: provider decision for PCV13 or PPSV23 based on CDC guidelines and past history of pneumonia vaccinations, if any . g) Interview with Registered Nurse (RN#113) currently responsible for the facility's Infection control program, on 09/12/19 at 10:56 AM, revealed after review of R#81 and R#37 medical records, RN#113 verified that there was no evidence in R#81 and R#37's medical records indicating education or information about PCV13 was provided. Also, there was no evidence the PCV13 vaccine was ever offered as an option to the residents or their representatives. There was no evidence of any kind of follow up after the initial refusal of PPSV23 by R#81 and R#37's representatives or after the revision of the facility's consent forms for Pneumonia vaccine.",2020-09-01
439,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-01-11,550,E,0,1,JURJ11,"Based on observation, staff interview and policy review, the facility failed to promote care for residents in a manner that maintained or enhanced dignity. The staff entered four (4) resident rooms without knocking, identifying themselves, or obtaining permission. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #43, #49, #52, and #62. Facility census: 79. Findings include: a) Resident #43 An observation on 01/10/18 at 7:55 AM revealed Licensed Practical Nurse (LPN) #38 entered the resident's room during medication observation without knocking, identifying herself, or obtaining permission from the resident. b) Resident #49 An observation on 01/10/18 at 8:05 AM revealed LPN #38 entered the resident's room during medication observation without knocking, identifying herself, or obtaining permission from the resident. c) Resident #62 An observation on 01/10/18 at 8:11 AM revealed LPN #38 entered the resident's room during medication observation without knocking, identifying herself, or obtaining permission from the resident. An interview with LPN #38 on 01/10/18 at 8:15 AM revealed the LPN forgot to knock on the resident doors before entering. The LPN stated she was busy focusing on the medications and forgot to knock and introduce herself. A review of the facility policy, on 01/10/18 at 11:00 AM, titled Resident Dignity & Personal Privacy with a revision date of (MONTH) 2007, stated the staff are to knock on doors before entering and announce your presence. b) Resident #52 On 01/08/18, at 10:00 a.m., while interviewing Resident #5, Nurse Aide (NA) #59 came into the resident's room without knocking on the door. On 01/10/18, at 2:52 p.m., the administrator was informed about NA #59 coming into the resident's room without knocking on the door. No further information was provided.",2020-09-01
440,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-01-11,561,D,0,1,JURJ11,"Based on interview and medical record review, the facility failed to ensure one (1) of 30 residents had been able to make choices about aspects of their life that were significant to them. Resident #52 was not offered a choice regarding why type of eggs he was served. He wanted fried or boiled eggs. Resident identifier: #52. Facility census: 79. Findings include: a) Resident #52 During an interview, on 01/08/18 at 10:09 a.m., Resident #52 said he liked fried and boiled eggs but did not get these. He said he had mentioned this to Assistant Account Manager (AAM) #70. On 01/09/18 at 10:35 a.m. Account Manager (AM) #66 was asked what type of eggs the facility served. He said they used liquid eggs but no fried or boiled eggs. AM #66 said he could start getting eggs to fry or boil. At 10:40 a.m., on 01/09/18, AAM#70 was asked if the resident had ever mentioned anything to her about wanting fried or boiled eggs. She said he had asked her for those type of eggs but she told him they were not on the menu.",2020-09-01
441,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-01-11,580,G,0,1,JURJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to immediately notify the physician of significant changes in Resident #10's skin integrity, and/or to commence a new form of treatment. This delay in treatment resulted in actual harm to Resident #10 who developed necrotic tissue in a heel pressure ulcer injury. Because of conflicting medical record information, it is unclear when the pressure wound originated. After the facility assessed necrotic changes in a heel wound fourteen (14) days after admission to the facility, it was another eight (8) days before a new form of treatment commenced. Additionally, the facility also failed to notify the medical power of attorney when the necrotic tissue was first assessed. This affected one (1) of thirty (30) sampled residents. Resident identifier: #10. Facility census: 79. Findings include: a) Resident #10 1. Record review The following details conflicting dates concerning the inception and status of the pressure wound: --Review of the medical record on 01/09/18 found the lack of accurate, ongoing monitoring of a pressure injury to the right heel initially, and conflicting assessments as follows: --The Nursing Admission Data Collection, dated 08/03/17, assessed under section L that the resident had no skin issues. The nurse at admission assessed she was dependent on staff for eating, toileting, chair/bed-to-chair transfer. The nurse assessed that her body appearance was well-nourished; cognition with short -term memory loss; confusion; primary [DIAGNOSES REDACTED]. --The weekly nursing Skin Review by licensed practical nurse #6, dated 08/03/17, assessed that her skin was intact, with no redness, no bruising, no open areas. --The Physical Therapy Plan of Care, with start date 08/04/17, stated Skin Integrity: Bilateral posterior heels - slow rebounding tissue with depression L (Left heel) = 0.6 cm (centimeters); R (Right heel) = 0.5 cm. Therapy's goal date of 08/17/17 was for the patient to demonstrate improved skin integrity of bilateral heels with delayed tissue rebound to depression as follows: L (Left heel) = 0.4 cm; R (Right heel) = 0.3 cm. --The Order Summary Report for August, (YEAR) included a physician's orders [REDACTED]. The start date of this order was 08/07/17, which was four (4) days after she came to the facility. --The admission minimum data set (MDS), with assessment reference date (ARD) of 08/10/17, assessed under section M that the resident had no stage 1 or greater pressure ulcer and no unhealed pressure ulcers. --The weekly nursing Skin Review assessment by registered nurse #200, dated 08/10/17, stated pressure sore on R (right) heel, rook boots while in bed. There was no description of the wound as to its size or appearance or staging or other type of identification. Review of the medical record found no corresponding nurse progress notes or assessments related to this skin review assessment entry. --The weekly nursing Skin Review assessment by licensed nurse #300, dated 08/17/17, stated (typed as written) Resident has a 3 by 3 necrotic area to outside of right heal. Treatment ordered. Review of the medical record found no treatment ordered beyond the Rooke boots. --Review of the medical record found no situation, background, assessment, request (SBAR) for this change of condition of necrotic 3.0 by 3.0 cm area of tissue on the right heel, which was first identified on 08/17/17. --Review of a (name of hospital) emergency room encounter for an unwitnessed fall at the facility was reviewed. She sustained a laceration to the right hand, and a skin avulsion to the right forearm. She was non-verbal at baseline with history of altered mental status secondary to dementia. She would follow up within the next two (2) days with her primary physician for wound check, and with wound care as scheduled. Discharge instructions included a consult with the wound care clinic for complex right forearm wound. The wound care clinic appointment was scheduled for 08/25/17. --Review of physician progress notes [REDACTED]. He wrote has a heel wound as well, which included no descriptions, staging, or measurement. --Review of a (name of wound care center) Comprehensive Wound Center History and Physical, dated 08/25/17, addressed that the resident's daughter reports concerns of wound to the right heel. States she noticed a dark area to heel over six (6) weeks ago. Daughter unsure what wound is being dressed with. Wears Rooke boots while in bed. Patient is immobile and dependent for transfers. Daughter reports patient is in bed or wheelchair. The Wound Center physician on 08/25/17 assessed the presence of a right calcareous (heel) deep --tissue injury (DTI) pressure ulcer, 2.5 by 3.5. The physician described the wound base as soft eschar firmly attached without fluctuance.with no undermining/tunneling. There was no drainage. The peri wound skin was clean, absent of [DIAGNOSES REDACTED]//warmth. A picture of the wound revealed it was located on the outer part of the right heel. --The 08/25/17 report of consultation from (name of wound care clinic) assessed a DTI pressure ulcer to the right heel. The clinic recommended to clean the wound with wound cleanser; cover with border silver foam, change it every other day; keep dry. --The Wound Center also stated to Elevate heels when in bed or use offloading waffle boots. Rooke boots for shearing prevention but does little help for pressure. F/U (follow-up) 5 (five) wks (weeks) for R (right) heel. --Review of the medical record found the resident's physician order, dated 08/25/17, to clean the right heel pressure ulcer with wound cleanser; keep dry; cover with border silver foam every two (2) days. --A physician's orders [REDACTED]. --The first nurse progress note in the electronic health record that mentioned the pressure wound of the right heel occurred on 08/28/17 at 12:33 p.m. In this note, the nurse addressed that the resident went to an appointment at the (name of wound care clinic) on 08/25/17. The consultation report states .3. Pressure ulcer to R (right) heel. Cver with border silver foalm, change QOD (every other day). Clean w/ (symbol for with) wound cleaner. Keep dry. DO NOT apply any ointments to wound. If area opens and begins to dry please callw/new orders. Elevate heels when in bed or use offloadin gwaffle boots. Rooke boots for shearing prevnetion but does little help for pressure. Follow-up in five (5) weeks for right heel. --A skin/wound note dated 09/01/17 by the director of nursing stated (typed as written) Resident admitted to facility with unstageable pressure ulcer to outer aspect of right heel. Wound 3 by 3 cm black necrotic area. No drainage. No discomfort noted during dressing change. Heels elevated while in bed on pillow. Protective boot at all times. This was the second nurse progress note in the electronic health record that mentioned the pressure wound of the right heel. --The 09/01/17 30-day MDS assessed that she had one unstageable pressure ulcer, and it was not present upon admission or reentry. It was assessed as 3.0 by 3.0. with eschar. --The current care plan contained a focus for being at risk for further skin breakdown, as she has a history of pressure ulcers, impaired mobility, and incontinence. The date of initiation was 08/08/17. Interventions include a full body check weekly and document. Another intervention directed to inform the family of any new area of skin breakdown. It did not mention the pressure reducing boot. It did not mention any description of any type of current pressure ulcer that she may potentially have had. --The current care plan also contained a focus for an unstageable pressure ulcer to the right heel. The date this focus was initiated was 08/28/17. Interventions included pressure relieving boots on at all times while in bed, with initiation date of 10/04/17. (As a note, it did not specify which or what type of boot.) Another intervention included weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate, with initiation date of 08/28/17. --A nurse progress note dated 09/12/17 addressed that the order for Rooke boots to be worn while in bed was discontinued due to the resident now wearing waffle boots. --A physician order [REDACTED]. --A physician order [REDACTED]. This order is still current on the (MONTH) (YEAR) MAR. --A skin wound note from the assistant director of nursing (ADON) dated 10/04/17 described the pressure ulcer to the right heel as unstageable, and measured 3.8 by 2.9 cm. She assessed the wound bed as black eschar with yellow slough edges, moderate amount of serous drainage on the old dressing, and a slight odor noted from the wound. She cleaned it with soap and water, applied Santyl, and covered it with gauze and a bioclusive dressing. --A nursing note dated 10/30/17 addressed the resident went to the wound center this day for debridement of the right heel, and the daughter accompanied the resident. --A nursing note by the ADON on 11/17/17 assessed the wound as a Stage III pressure ulcer to the right heel measuring 2.4 by 3.0 by 0.4 cm. There were two (2) small areas of slough. --On 12/11/17, the resident returned to the same wound care clinic. The physician at the wound care clinic applied silver [MEDICATION NAME] to the wound due to hypergranulation. The physician termed it a Stage 3 decubitus ulcer to the right heel. She gave new orders to clean with wound cleanser, discontinue Santyl and Dakins dressing, and apply silver alginate to wound and cover with border foam and change every two (2) days. She also ordered to Continue aggressive wound offloading. --A nurse progress note on 12/11/17 addressed that the resident visited the wound center today with (name of doctor). The nurse wrote the new orders into the nursing note, which included to Continue aggressive wound offloading. 2. Interview with the Assistant Director of Nursing On 01/09/18, an interview was conducted with the assistant director of nursing (ADON) from 2:15 PM to 3:15 PM revealed the following: --Upon inquiry, she said she did not see any treatment orders for the pressure wound of the right heel prior to 08/25/17. She said she could only see the Rooke boots order prior to 08/25/17. --Upon inquiry as to when the facility first identified the pressure ulcer to the right heel, she said she assumed the resident came in with it. She acknowledged the 08/03/17 nursing admission assessment and 08/03/17 weekly skin assessment found her skin intact, as did the admission MDS with ARD 08/10/17. She agreed the nurse who wrote the 08/10/17 weekly skin assessment about the pressure ulcer to the right heel should have described the pressure ulcer's appearance and size, but she did not do so. --She said had the nurse completed an SBAR, they would have been sure to notify the physician and family and get treatment orders. --She agreed that the first mention of necrotic tissue on the right heel occurred during the 08/17/17 weekly skin assessment. Upon inquiry as to whether the medical power of attorney (MPOA) or the physician was notified of the necrosis on 08/17/17, she said she did not see any evidence of those notifications, did not see any evidence of measurements, and no SBAR was completed by the nurse on 08/17/17. She provided a copy of the facility's policy on Changes in Resident Condition. 3. Review of facility policy Review of the facility's policy in Changes in Resident Condtion (revised (MONTH) (YEAR)) stated: --The nursing staff, the resident, the attending physician and the resident's legal representative are notified when changes in the resident's condition occur. Communication with the Interdisciplinary Team and caregivers is also important to ensure that consistency and continuity are maintained for the resident's benefit. --Guideline #2 in this policy stated Prompt notification is required when . a signficant change in the resident's attending physical, mental , or psychosocial status, including a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications; or a need to alter treatemnt signficantly. --Guideline #4 in this policy stated The SBAR Communication Form and the Progress not are used to: a. Assess and document changes in condition in an efficient and effective manner; b. Provide assessment information to the physicain, and c. Provide clear comprehensive documentation. --Guideline number #4 this policy also stated Changes in the resident status that affect the problem (s)/goals(s) or approaches(es) on his or her care plan are documented as revisions and communicated to the interdisciiplinacy caregivers. --Under Documentation requirements, this policy listed the SBAR Communication Form, Progres Note, and 24-Hour Report. 4. Observation of the wound Observation of the right heel on 01/09/18 at 3:45 p.m. found a new deep tissue injury was present which had not yet been identified by the facility. The inner right heel had a swollen, reddened area approximately two and one-half inches in diameter. The middle of the wound contained an irregular shaped, maroon discoloration. The ADON measured the darkened, maroon discolored area at 2.0 by 2.3 centimeters (cm). The ADON said this was a brand new deep tissue injury first identified at this time when the old dressing was removed. She said the heel was dressed yesterday morning, and there was no mention of a new suspected deep tissue injury at that time on the inner aspect of the right heel. She surmised it developed between then and now. The ADON said the physician's assistant was in the building and they notified him to look at the new wound. He also wrote new orders. The MPOA was notified of the change in condition. A pair of white boots lined with sheepskin lay in her bed which staff had removed prior to the dressing change. After the dressing change, the resident wore dark colored padded boots on both feet instead of the white Rooke boots 5. Interview with Director of Nursing (DON) and ADON An interview was conducted with the director of nursing (DON) on 01/09/18 at 4:30 PM. A discussion ensued about the lack of evidence of physician or MPOA notification at least when the wound was assessed with [REDACTED]. Also, there was no confirmed date of the initial onset of the pressure wound of the right heel, or measurements/assessments/treatment to show evidence of any ongoing monitoring and assessment. The DON said she addressed that whole issue in (MONTH) related to this resident's pressure ulcer, and she brought it to QA (Quality Assessment and Assurance) in (MONTH) (YEAR). She said at that time, they had a lot of agency nurses, and that was the root of the problem. She said the nurse who first documented the pressure ulcer on 09/10/17 lacked long-term experience. She said that nurse no longer works at the facility. She was informed that this would be cited, and a list of copies of needed documents was given to her and the ADON for tomorrow. During an interview with the ADON on 01/10/18 at 2:15 PM, she said she could still find no information on notification of the physician or family of the pressure wound prior to her going out the hospital on [DATE] after the fall. She said she still could find no information or notification of the physician or family of the pressure would on 08/17/17 when the nurse assessed and documented necrotic tissue on the right heel. Upon inquiry, she said both she and the DON informed the administrator yesterday of the pressure ulcer issue that would be cited. Interviews were conducted with the ADON and the DON on 01/11/17 at 8:00 AM. The ADON clarified the resident has had two (2) debridements of the pressure wound to the right heel, once on 10/30/17 and again on 12/11/17. She clarified that the (name of hospital) on 08/20/17 gave orders for a referral to the (name of wound care clinic), which the resident first attended on 08/25/17. She clarified that the only physician or physician's assistant progress notes that they could find which mentioned a pressure ulcer since admission were the 08/22/17 and the 01/09/18 notes, both of which she made copies of yesterday. She clarified that they were still unable to find any evidence of the facility's physician's treatment orders for the pressure wound to the right heel prior to 08/25/17, other than the Rooke boots. The lack of documentation to support the notification of the physician that Resident #10 had a pressure ulcer with necrotic tissue, lack of evidence to support when the pressure ulcer developed, and lack of physician treatment orders all contributed in actual harm to Resident #10.",2020-09-01
442,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-01-11,641,D,0,1,JURJ11,"Based on medical record review and staff interview, the facility failed to ensure the accuracy of minimum data set assessments (MDS). The admission MDS and a quarterly MDS incorrectly assessed the status of Resident #10's pressure ulcers. This was evident for one (1) of thirty (30) sampled residents. Resident identifier: #10. Facility census: 79. Findings include: a) Resident #10 The medical record was reviewed on 01/09/18. Section M of the admission MDS, with assessment reference date (ARD) 08/10/17, assessed this resident had no stage 1 or greater pressure ulcers. It assessed that she had no unhealed pressure ulcers. The weekly skin assessment, dated 08/10/17, and completed by former registered nurse Employee #200, was reviewed. It assessed this resident had a pressure sore on the right heel, and wore Rooke boots while in bed. An interview was conducted with the assistant director of nursing (ADON) on 01/09/18, ending at 3:15 p.m. She said the admission MDS, with ARD 08/10/17, incorrectly assessed that the resident had no pressure ulcer. She acknowledged that nursing's 08/10/17 weekly skin review stated that the resident had a pressure sore on the right heel. Based on her review of nurse progress notes and nursing assessments, she said this 08/10/17 weekly skin review was the first mention by nursing of the right heel pressure ulcer, and it should have been captured in the admisison MDS. Review of the quarterly minimum data set (MDS), with assessment reference date (ARD) of 10/30/17, found that it assessed a Stage 2 pressure ulcer that was not present upon admission. It assessed the onset date of the oldest Stage 2 pressure ulcer as 10/17/17. This was in addition to an unstageable pressure ulcer covered by slough and/or eschar, which was also not present upon admission. A situation, background, assessment, request (SBAR) communication form dated 10/11/17, reported a change in condition as resident has a pressure ulcer starting on her coccyx. The reporting nurse registered nurse #200) stated she thought the resident is sitting on her buttocks too long during the day. An interview was conducted with the assistant director of nursing (ADON) on 01/09/18, ending at 3:15 p.m. She said the quarterly MDS, with ARD 10/30/17, was inaccurate in section M when it assessed an unhealed Stage 2 pressure ulcer with onset date of 10/17/17. The ADON said registered nurse Employee #200 completed the 10/11/17 SBAR, and asked the ADON to look at the resident's coccyx. The ADON said she completed an assessment of the resident's coccyx, and found it was only slightly reddened and had no opened area. The ADON said she forgot to document her findings that there was no Stage 2 pressure ulcer, and no one informed the MDS nurse of the correction.",2020-09-01
443,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-01-11,657,D,0,1,JURJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to revise care plans for one (1) of thirty (30) residents. Resident #52's care plan had not been revised to show his current level of interest for activities. Resident #66's care plan for a tube feeding had not been revised. Resident identifiers: #52, #66. Facility census: 79. Findings include: a) Resident #52 On 01/08/18 at 9:36 AM during an interview, Resident #52 said he did not care for most of the group activities. He indicated he did not want to get up in his wheelchair, and preferred to remain in bed. He said he had been at a different nursing home where they gave out pictures to look for certain items as well as word search puzzles to complete. He said he liked these type of puzzles and would enjoy doing them. He said the facility had not provided any for him in a while. He said he primarily watched television and he had a cell phone. On 01/09/18 at 4:00 PM Activity Manager (AM) #7 said Resident #52 was more active in the summer/fall when the weather was nice. AM #7 said the resident would move around the facility in his wheelchair and sit outside during warm weather. AM #7 said it had been several weeks since the resident had been up out of bed and in his wheelchair. She said for the past several weeks he had remained in bed. A progress note, by AM #7, dated 01/09/19 at 5:15 PM stated, Went to visit (Resident #52) about independent activities. Took him word searches and picture puzzles as he requested. During an interview, on 01/10/18 at 10:00 AM, Resident #52 said he had completed all of his word search and picture puzzles and would enjoy doing more. A review of the resident's care plan for activities revealed the following interventions: --Please assist me with my phone when I need help. --Provide with activities calendar. --The resident's preferred activities are: being outside when the weather is nice, watching TV (television) and talking to others. --Prefer to spend most of my time resting in bed watching TV and talking on the phone, Encourage me to spend more time oob (out of bed) and out of my room throughout each day. There was no indication the care plan for activities had been revised to include possible recreational stimulating activities since the resident was no longer wanting to get out of bed. No further interventions beyond watching TV and talking with others had been initiated. AM #7 confirmed the resident had few visitors. b) Resident #66 An observation, on 01/10/18 at 7:15 AM, revealed Resident #66's head of bed was elevated approximately 30 degrees. The resident had slid down in the bed with their head flat. An observation, on 01/10/18 at 7:45 AM, revealed Resident #66's head of bed was elevated approximately 30 degrees. The resident had slid down in bed with their head flat. Upon closer observation, it was discovered the resident was receiving an enteral feeding via a pump. An immediate interview, on 01/10/18 at 7:45 AM, with Licensed Practical Nurse (LPN) #3, revealed the enteral feeding is started daily at 6:00 AM. The LPN stated the resident's head should be elevated during his feeding. The LPN stated she would seek assistance from another staff member to help pull the resident up in bed. The LPN stated the resident slides down in bed all the time. The LPN stated she had not communicated the resident's frequent sliding down in bed to her supervisor. The LPN stated there were no current interventions in place to prevent the resident from sliding down. A record review, on 01/10/18 at 7:50 AM, revealed the resident was initially admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Further record review, on 01/10/18 at 7:55 AM, revealed the resident had a physicians enteral feed order for Glucerna 1.5 at 94 ml (milliliters) q (every) hr (hour) times 16 hours via pump with a start time daily of 6:00 AM. The order was dated 01/05/18. A review of the Care Plan was conducted on 01/10/18 at 8:20 AM. The Care Plan, with a revision date of 12/19/17, contained the focus of tube feeding and care needs with the intervention of the head of the bed being elevated 30 degrees at all times. The care plan did not include the resident sliding down in the bed when the head is elevated. An interview, on 01/10/18 at 8:45 AM, with Nurse Aide (NA) #57, revealed the resident slides down a lot and has to be pulled up at least twice a shift if not more. The NA stated she has not reported this behavior to anyone. The NA stated everyone knows he does it. An interview with the Director of Nursing (DON), on 01/10/18 at 8:55 AM, revealed she had no idea the resident slid down in bed especially during enteral feedings. The DON stated any staff member who knew the resident was sliding down in bed should have reported it immediately. The DON stated the resident's behavior should have been added to the Care Plan and interventions should have been put into place to ensure the resident remained elevated.",2020-09-01
444,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-01-11,684,E,0,1,JURJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, observation and record review, the facility failed to ensure and provide needed care and services for two (2) of thirty (30) LTCSP (Long Term Care Survey Process) sample residents, in accordance with professional standards of practice. The facility failed to obtain an order for [REDACTED]. Resident identifiers: #16, and #6. Census: 79 Findings include: a) Resident #16 On 01/08/18 at 04:13 PM, observation of Resident #16 revealed no foley catheter drainage bag with privacy cover, as ordered, was seen. Review of a significant change minimum data set (MDS) with an assessment reference date (ARD) 11/07/17, on 01/09/18 at 10:00 AM, revealed resident's mental status was moderately impaired, the resident needed extensive assistance with activities of daily living, and had an indwelling catheter. Pertinent [DIAGNOSES REDACTED]. On 01/09/18 at 10:43 AM, review of care plan revealed the resident has 18 french foley catheter with 10 cc balloon. Care plan addressed foley catheter care as well as weekly cleaning of privacy bag. There was no mention or care for a leg drainage bag. Review of records revealed orders for foley catheter care and foley catheter drainage bag. There was no order for a leg drainage bag or planned care for a leg drainage bag. Interview with the Director of Nursing (DON) on 01/10/18 at 09:58 AM, revealed there was no order for a drainage leg bag and the DON confirmed there should have been an order for [REDACTED]. I agree we should have notified the physician and got an order. I looked and there is no order. b) Resident #6 The medical record was reviewed on 01/09/18. [DIAGNOSES REDACTED]. physician's orders [REDACTED]. The physician also ordered [MEDICATION NAME] 5-325 mg. every twelve (12) hours as needed (prn) for pain. [MEDICATION NAME] is an opiod pain medication. Opiods block pain signals in the brain and in other parts of the central nervous system by attaching to something called mu-receptors. When opiods attach to mu-receptors in the bowel, they can cause opiod induced constipation (OIC). OIC is on of the most common side effects of opiod use, and can last for the length of treatment. Further review of physician's orders [REDACTED]. If the laxative was ineffective, the physician ordered one (1) application of Fleet enema rectally. Review of the resident's bowel movement records from 12/01/17 through 01/09/18 revealed three (3) instances where the resident went greater than three (3) days without a bowel movement, as follows: --She had a bowel movement on 12/01/17, and no evidence of another until six (6) days later on 12/07/17. --She had a bowel movement on 12/14/17, and no evidence of another until six (6) days later on 12/20/17. --She had a bowel movement on 12/30/17, and no evidence of another until five (5) days later on 01/04/18. Review of the medication administration records (MAR) for (MONTH) (YEAR) and (MONTH) (YEAR) found no evidence that Milk of Magnesia or Fleet enema was administered. Review of nurse progress notes for the time frames of 12/01/17 through 12/07/17, and 12/14/17 through 12/20/17, and 12/30/17 through 01/04/18 revealed no evidence that she had been offered a laxative, or that the lack of bowel movements for greater than three (3) days had occurred, or that any abdominal assessments and/or bowel sound assessments were completed by nurses after she went greater than three (3) days with no bowel movement. Review of the care plan revealed interventions to observe for side effects of pain medication, and observe for constipation. Interviews were completed with licensed nurse #56 and registered nurse #47 on 01/10/18 at 9:24 AM They said she is always incontinent. An interview was completed with the administrator and the director of nursing on 01/10/18 at 1:30 PM They said they have standing orders for bowel protocol to treat on the third day if a resident has no bowel movement. No further information was provided after informing them that there was no evidence per MAR indicated [REDACTED]. The DON said the resident used to be on Senna daily, but the resident refused it. On 01/10/18 at 1:35 PM an interview was conducted with the resident. Upon inquiry, she said she sometimes has trouble with constipation. At this time, informed her that she has orders for Milk of Magnesia when needed for constipation.",2020-09-01
445,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-01-11,686,G,0,1,JURJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to identify and/or adequately monitor a pressure injury, which resulted in actual harm to the resident. Resident #10 came to the facility with unclear identification date and description of a pressure wound on the right heel. Initially, the facility failed to adequately assess and/or monitor the pressure wound prior to the development of necrotic tissue on the right heel. Once the necrotic tissue was assessed, it was another eight (8) days before treatment was initiated beyond the use of sheepskin lined boots. The facility also failed to prevent the development of a second pressure ulcer on a resident with a current [DIAGNOSES REDACTED]. Its existence was unknown to the facility prior to surveyor intervention when asked to observe the wound. This affected one (1) of thirty (30) sampled residents. Resident identifier: #10. Facility census: 79. Findings include: a) Resident #10 1. Record review The resident first came to the facility on [DATE]. Review of the medical record on 01/09/18 found the lack of accurate, ongoing monitoring of a pressure injury to the right heel initially, and conflicting assessments as follows: --The Nursing Admission Data Collection, dated 08/03/17, assessed under section L that the resident had no skin issues. The nurse at admission assessed she was dependent on staff for eating, toileting, chair/bed-to-chair transfer. The nurse assessed that her body appearance was well-nourished; cognition with short -term memory loss; confusion; primary [DIAGNOSES REDACTED]. --The weekly nursing Skin Review by licensed nurse #6, dated 08/03/17, assessed that her skin was intact, with no redness, no bruising, no open areas. --The Physical Therapy Plan of Care, with start date 08/04/17, stated Skin Integrity: Bilateral posterior heels - slow rebounding tissue with depression L (Left heel) = 0.6 cm (centimeters); R (Right heel) = 0.5 cm. Therapy's goal date of 08/17/17 was for the patient to demonstrate improved skin integrity of bilateral heels with delayed tissue rebound to depression as follows: L (Left heel) = 0.4 cm; R (Right heel) = 0.3 cm. --The Order Summary Report for August, (YEAR) included a physician's orders [REDACTED]. The start date of this order was 08/07/17, which was four (4) days after she came to the facility. --The admission minimum data set (MDS), with assessment reference date (ARD) of 08/10/17, assessed under section M that the resident had no stage 1 or greater pressure ulcer and no unhealed pressure ulcers. --The weekly nursing Skin Review assessment by registered nurse #200, dated 08/10/17, stated pressure sore on R (right) heel, rook boots while in bed. There was no description of the wound as to its size or appearance or staging or other type of identification. Review of the medical record found no corresponding nurse progress notes or assessments related to this skin review assessment entry. --The weekly nursing Skin Review assessment by licensed nurse #300, dated 08/17/17, stated (typed as written) Resident has a 3 by 3 necrotic area to outside of right heal. Treatment ordered. --Review of the medical record found no situation, background, assessment, request (SBAR) for this change of condition of necrotic 3.0 by 3.0 cm area of tissue on the right heel, which was first identified on 08/17/17. --Review of a (name of hospital) emergency room encounter for an unwitnessed fall at the facility was reviewed. She sustained a laceration to the right hand, and a skin avulsion to the right forearm. She was non-verbal at baseline with history of altered mental status secondary to dementia. She would follow up within the next two (2) days with her primary physician for wound check, and with wound care as scheduled. Discharge instructions included a consult with the wound care clinic for complex right forearm wound. The wound care clinic appointment was scheduled for 08/25/17. --Review of physician progress notes [REDACTED]. He wrote has a heel wound as well, which included no descriptions, staging, or measurement. --Review of a (name of wound care center) Comprehensive Wound Center History and Physical, dated 08/25/17, addressed that the resident's daughter reports concerns of wound to the right heel. States she noticed a dark area to heel over six (6) weeks ago. Daughter unsure what wound is being dressed with. Wears Rooke boots while in bed. Patient is immobile and dependent for transfers. Daughter reports patient is in bed or wheelchair. --The Wound Center physician on 08/25/17 assessed the presence of a right calcareous (heel) deep tissue injury (DTI) pressure ulcer, 2.5 by 3.5. The physician described the wound base as soft eschar firmly attached without fluctuance.with no undermining/tunneling. There was no drainage. The peri wound skin was clean, absent of [DIAGNOSES REDACTED]//warmth. A picture of the wound revealed it was located on the outer part of the right heel. --The 08/25/17 report of consultation from (name of wound care clinic) assessed a DTI pressure ulcer to the right heel. The clinic recommended to clean the wound with wound cleanser; cover with border silver foam, change it every other day; keep dry. --The wound care clinic also stated to Elevate heels when in bed or use offloading waffle boots. Rooke boots for shearing prevention but does little help for pressure. F/U (follow-up) 5 (five) wks (weeks) for R (right) heel. --Review of the medical record found the resident's physician order, dated 08/25/17, to clean the right heel pressure ulcer with wound cleanser; keep dry; cover with border silver foam every two (2) days. --A physician's orders [REDACTED]. --The current care plan contained a focus for being at risk for further skin breakdown, as she has a history of pressure ulcers, impaired mobility, and incontinence. The date of initiation was 08/08/17. Interventions include a full body check weekly and document. Another intervention directed to inform the family of any new area of skin breakdown. It did not mention the pressure reducing boot. It did not mention any description of any type of current pressure ulcer that she may potentially have had. --The current care plan also contained a focus for an unstageable pressure ulcer to the right heel. The date this focus was initiated was 08/28/17. Interventions included pressure relieving boots on at all times while in bed, with initiation date of 10/04/17. (As a note, it did not specify which or what type of boot.) Another intervention included weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate, with initiation date of 08/28/17. --The first nurse progress note in the electronic health record that mentioned the pressure wound of the right heel occurred on 08/28/17 at 12:33 p.m. In this note, the nurse addressed that the resident went to an appointment at the (name of wound care clinic) on 08/25/17. The consultation report states .3. Pressure ulcer to R (right) heel. Cover with border silver foam, change QOD (every other day). Clean w/ (symbol for with) wound cleaner. Keep dry. DO NOT apply any ointments to wound. If area opens and begins to dry please call w/new orders. Elevate heels when in bed or use offloading waffle boots. Rooke boots for shearing prevention but does little help for pressure. Follow-up in five (5) weeks for right heel. --A skin/wound note dated 09/01/17 by the director of nursing stated (typed as written) Resident admitted to facility with unstageable pressure ulcer to outer aspect of right heel. Wound 3 by 3 cm black necrotic area. No drainage. No discomfort noted during dressing change. Heels elevated while in bed on pillow. Protective boot at all times. This was the second nurse progress note in the electronic health record that mentioned the pressure wound of the right heel. --The 09/01/17 30-day MDS assessed that she had one unstageable pressure ulcer, and it was not present upon admission or reentry. It was assessed as 3.0 by 3.0. with eschar. --A nurse progress note dated 09/12/17 addressed that the order for Rooke boots to be worn while in bed was discontinued due to the resident now wearing waffle boots. --A physician order [REDACTED]. --A physician order [REDACTED]. This order is still current on the (MONTH) (YEAR) MAR. --A skin wound note from the assistant director of nursing (ADON) dated 10/04/17 described the pressure ulcer to the right heel as unstageable, and measured 3.8 by 2.9 cm. She assessed the wound bed as black eschar with yellow slough edges, moderate amount of serous drainage on the old dressing, and a slight odor noted from the wound. She cleaned it with soap and water, applied Santyl, and covered it with gauze and a bioclusive dressing. --A nursing note dated 10/30/17 addressed the resident went to the wound center this day for debridement of the right heel, and the daughter accompanied the resident. --A nursing note by the ADON on 11/17/17 assessed the wound as a Stage III pressure ulcer to the right heel measuring 2.4 by 3.0 by 0.4 cm. There were two (2) small areas of slough. - -n 12/11/17, the resident returned to the same wound care clinic. The physician at the wound care clinic applied silver [MEDICATION NAME] to the wound due to hypergranulation. The physician termed it a Stage 3 decubitus ulcer to the right heel. She gave new orders to clean with wound cleanser, discontinue Santyl and Dakins dressing, and apply silver alginate to wound and cover with border foam and change every two (2) days. She also ordered to Continue aggressive wound offloading. - A nurse progress note on 12/11/17 addressed that the resident visited the wound center today with (name of doctor). The nurse wrote the new orders into the nursing note, which included to Continue aggressive wound offloading. 2. Interview with Assistant Director of Nursing On 01/09/18, an interview was conducted with the assistant director of nursing (ADON) from 2:15 p.m. to 3:15 PM. Upon inquiry, she said she did not see any treatment orders for the pressure wound of the right heel prior to 08/25/17. She said she could only see the Rooke boots order prior to 08/25/17. Upon inquiry as to when the facility first identified the pressure ulcer to the right heel, she said she assumed the resident came in with it. She acknowledged the 08/03/17 nursing admission assessment and 08/03/17 weekly skin assessment found her skin intact, as did the admission MDS with ARD 08/10/17. She agreed that the nurse who wrote the 08/10/17 weekly skin assessment about the pressure ulcer to the right heel should have described the pressure ulcer's appearance and size. She said had the nurse completed an SBAR, they would have been sure to notify the physician and family and get treatment orders. She agreed that the first mention of necrotic tissue on the right heel occurred during the 08/17/17 weekly skin assessment. Upon inquiry as to whether the medical power of attorney (MPOA) or the physician was notified of the necrosis on 08/17/17, she said she did not see any evidence of those notifications, or evidence of any measurements, and no SBAR was completed by the nurse on 08/17/17. Upon request to observe the wound to the right heel, the ADON said she would first gather the supplies, then dress the wound while observed. 2. Observation of the pressure ulcer Observation of the right heel on 01/09/18 at 3:45 p.m. found a new deep tissue injury was present which had not yet been identified by the facility. The inner right heel had a swollen, reddened area approximately two and one-half inches in diameter. The middle of the wound contained an irregular shaped, maroon discoloration. The ADON measured the darkened, maroon discolored area at 2.0 by 2.3 cms. The DON said this was a brand new deep tissue injury first identified at this time when the old dressing was removed. She said the heel was dressed yesterday morning, and there was no mention of a new suspected deep tissue injury at that time on the inner aspect of the right heel. She surmised it developed between then and now. The ADON said the physician's assistant was in the building and they notified him to look at the new wound. He also wrote new orders. The MPOA was notified of the change in condition. A pair of white boots lined with sheepskin lay in her bed which staff had removed prior to the dressing change. After the dressing change, the resident wore dark colored padded boots on both feet instead of the white Rooke boots. The older pressure ulcer, located on the outer right heel, was similar to the 01/05/18 assessment which was 0.8 by 2.0 by 0.1 cms, with dry yellow/brown wound bed without drainage or foul odor. 3. Interviews On 01/09/18 at 4:15 p.m., an interview was conducted with the physician's assistant, Employee #400. Upon inquiry as to how often he and/or the physician assess the wounds, he said they have no set days to look at pressure ulcers, or conduct scheduled wound care clinics. Rather, they depend on nurses to notify them of changes, as they did just now. An interview was conducted with the director of nursing (DON) on 01/09/18 at 4:30 p.m. A discussion ensued about the lack of evidence of physician or MPOA notification at least when the wound was assessed with [REDACTED]. Also, there was no confirmed date of the initial onset of the pressure wound of the right heel, or measurements/assessments/treatment to show evidence of any ongoing monitoring and assessment. The DON said she addressed that whole issue in (MONTH) related to this resident's pressure ulcer, and she brought it to QA (Quality Assessment and Assurance) in (MONTH) (YEAR). She said at that time, they had a lot of agency nurses, and that was the root of the problem. She said the nurse who first documented the pressure ulcer on 0910/17 lacked long-term experience. She said that nurse no longer works at the facility. She was informed that this would be cited, and a list of copies of needed documents was given to her and the ADON for tomorrow. An interview was conducted with the director of rehab Employee #41, on 01/10/18 at 8:15 a.m. in Resident #10's room. Resident #10 sat in a chair in the hall at this time. Employee #41 found the white boots with the sheepskin in the resident's closet. She said they were Rooke boots. She said the dark colored ones lying in the chair at present, were the ones they put on her after yesterday afternoon's dressing change. She said they are called a Heel Medex. She said the Heel Medex is good for offloading, and is a prevalon type of boot. She said that based on her own experience, the Medex boot is better than the Rooke boot for offloading pressure. Upon inquiry, she said a waffle boot is plastic and filled with air. She said it can become hot and sweaty. She said it is air-filled, and that the air consistency does not remain the same consistently. She then returned to the therapy room. She said therapy treated this resident last fall with various modalities to reduce the pain from the pressure wound of the right heel and to promote its healing. She said they used different things last fall such as diathermy. She said that when the resident was discharged from therapy, that she no longer had pain in the pressure wound, and the wound looked like a skin patch ready to peel off. When asked about the waffle boots, she said she did not recall this resident ever having waffle boots in the past Four (4) other therapy staff personnel were present (no patients at this moment), and when asked, none of them could recall using waffle boots for this resident. Employee #41 said different products have different percentages of off-loading, pressure relief. She showed a picture in a catalogue of an off-loading boot she said she could order that is 100% off-loading. Upon inquiry, she said she has not been asked by nursing to select a pressure relieving boot for aggressive wound off-loading for this resident. She said that generally when the physician gives an order to nursing for pressure relieving foot coverings, that nursing use their own discretion to make selections. A second interview was conducted with Employee #41 on 01/10/18 at 9:15 a.m. for clarification. She said that an off-loading boot is a broad term, as there are different percentages of off-loading ability per boot. She said if she received an order from a physician for an off-loading boot, that she would have to contact the physician and ask for more specifics of what he wanted and needed for a resident. During an interview with the ADON on 01/10/18 at 2:15 p.m., she said she could still find no information on notification of the physician or family of the pressure wound prior to her going out the hospital on [DATE] after the fall. She said she still could find no information or notification of the physician or family of the pressure would on 08/17/17 when the nurse assessed and documented necrotic tissue on the right heel. Upon inquiry, she said both she and the DON informed the administrator yesterday of the pressure ulcer issue that would be cited. Interviews were conducted with the ADON and the DON on 01/11/17 at 8:00 a.m. The ADON clarified the resident has had two (2) debridements of the pressure wound to the right heel, once on 10/30/17 and again on 12/11/17. She clarified that the (name of hospital) on 08/20/17 gave orders for a referral to the (name of wound care clinic), which the resident first attended on 08/25/17. She clarified that the only physician or physician's assistant progress notes that they could find which mentioned a pressure ulcer since admission were the 08/22/17 and the 01/09/18 notes, both of which she made copies of yesterday. She clarified that they were still unable to find any evidence of the facility's physician's treatment orders for the pressure wound to the right heel prior to 08/25/17, other than the Rooke boots. Another interview was completed with the ADON on 01/11/17 at 9:45 a.m. Discussed with her what Employee #41 said about differing amounts of offloading per product, and that she has one she can order that is 100% offloading. The ADON said she does not really know that much about all the particulars for all of the boots. Informed her that the wound care clinic on 08/25/17 wrote that Rooke boot is good for shearing preventions, but no so good for offloading, and they recommended a waffle boot or elevating the feet on pillows. Informed her that the physician ordered a waffle boot for five (5) weeks, but the current recapitulation of physician's orders [REDACTED]. Rather, the order and MAR indicated [REDACTED]. The ADON listened and acknowledged. No further information was provided prior to exit. Following exit, the facility emailed a Rooke product advertisement/brochure, which stated in part that the Classic Rooke offloading boot was designed to protect the healing limb and help prevent pressure ulcers.",2020-09-01
446,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-01-11,693,J,0,1,JURJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide treatment and services to prevent potential complications, such as aspiration pneumonia, for a resident receiving enteral nutrition. Even though the head of the bed was elevated 30 degrees, Resident #66 was observed to be slid down in the bed with their head flat during an enteral feeding for approximately thirty (30) minutes. Upon interviewing the staff, a Licensed Practical Nurse (LPN) and a Nurse Aide (NA) were both aware the resident frequently slid down in bed allowing for their head not to be elevated during enteral feedings. Neither staff member reported this behavior. Further investigation revealed there were no interventions in place to help prevent the resident from sliding down in bed allowing their head to be flat during enteral feedings. These findings were determined to pose an immediate jeopardy to the health and well-being of Resident #66. The facility Administrator and Director of Nursing were notified of the immediate jeopardy on 01/10/18 at 10:20 AM. The facility provided a plan of correction on 01/10/18 at 11:40 AM. The immediacy of this deficient practice was abated on 01/10/18 at 11:55 AM. This identified failed practice had the potential to affect four (4) of four (4) residents who received enteral nutrition in the facility. Resident identifier: #66. Facility census: 79. Findings include: a) Resident #66 An observation, on 01/10/18 at 7:15 AM, revealed Resident #66's head of bed was elevated approximately 30 degrees. The resident was slid down in the bed with their head flat. An observation, on 01/10/18 at 7:45 AM, revealed Resident #66's head of bed was elevated approximately 30 degrees. The resident was in the same slid down position in bed with their head flat. Upon closer observation, it was discovered the resident was receiving an enteral feeding via a pump. An immediate interview, on 01/10/18 at 7:45 AM, with Licensed Practical Nurse (LPN) #3, revealed the enteral feeding is started daily at 6:00 AM. The LPN stated the resident's head should be elevated during his feeding. The LPN stated she would seek assistance from another staff member to help pull the resident up in bed. The LPN stated the resident slides down in bed all the time. The LPN stated she had not communicated the resident's frequent sliding down in bed to her supervisor. The LPN stated there were no current interventions in place to prevent the resident from sliding down. A record review, on 01/10/18 at 7:50 AM, revealed the resident was initially admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Further record review, on 01/10/18 at 7:55 AM, revealed the resident had a physicians enteral feed order for Glucerna 1.5 at 94 ml (milliliters) q (every) hr (hour) times 16 hours via pump with a start time daily of 6:00 AM. The order was dated 01/05/18. A review of the Care Plan was conducted on 01/10/18 at 8:20 AM. The Care Plan, with a revision date of 12/19/17, contained the focus of tube feeding and care needs with the intervention of the head of the bed being elevated 30 degrees at all times. The care plan did not include the resident sliding down in the bed when the head is elevated. An interview, on 01/10/18 at 8:45 AM, with Nurse Aide (NA) #57, revealed the resident slides down a lot and has to be pulled up at least twice a shift if not more. The NA stated she has not reported this behavior to anyone. The NA stated everyone knows he does it. An interview with the Director of Nursing (DON), on 01/10/18 at 8:55 AM, revealed she had no idea the resident slid down in bed especially during enteral feedings. The DON stated any staff member who knew the resident was sliding down in bed should have reported it immediately. The DON stated the resident's behavior should have been added to the Care Plan and interventions should have been put into place to ensure the resident remained elevated.",2020-09-01
447,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-01-11,745,D,0,1,JURJ11,"Based on medical record review and staff interview, the facility failed to ensure one (1) of thirty (30) residents received medically related social services necessary to maintain the highest practicable psyschosocial well-being. Resident #24 had three (3) pair of pants all of which were in the laundry and the resident had to go out to a medical appointment in shorts during winter weather. Resident identifier: #24. Facility census: 79. Facility census: a) Resident #24 On 01/08/18 at 1:17 PM, said it was hard to find pants to fit him because of his size. He said he went out to a medical appointment earlier in the day wearing only shorts. The area was experiencing cold, winter weather conditions on 01/08/18. Resident #24 said he had three (3) pair on pants but they were all in the laundry at the time of his appointment. Resident #24 said he had a hard time finding pants due to his size. On 01/09/18 at 4:18 PM, the Administrator #63 said she did not know the resident had went out to an appointment in shorts nor was she aware the resident only had three (3) pair of pants. At 4:25 PM on 01/09/18, Business Office Director ##51 said the resident had expressed a desire to get his personal spending allowance transferred to the facility. This money currently goes to the resident's family. The resident's family does not frequently visit or bring him clothing. The resident had no money at the facility to buy personal clothing. On 01/09/18 at 4:30 PM, Account Manager #77 said she knew the resident needed pants but due to his size it was hard to find anything that had been donated to the facility that he could wear. She also said she had tried a local establishment that had doanted clothing but had not been able to find any pants for the resident. On 01/09/18 at 4:45 PM, Administrator #63 provided information showing she had ordered the resident two (2) pair of fleece open-bottom pants.",2020-09-01
448,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-01-11,756,D,0,1,JURJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the pharmacist identified and reported irregularities to the attending physician and director of nursing, and those reports would be acted upon. A resident, whose [DIAGNOSES REDACTED]. On three (3) occasions in (MONTH) (YEAR) and (MONTH) (YEAR), the resident went greater than three (3) days with no bowel movement and no nursing interventions to treat the lack of bowel movements. The pharmacist failed to identify and report this irregularity to the physician and director of nursing. This was evident for one (1) of five (5) residents reviewed for unnecessary medications, out of thirty (30) sampled residents. Resident identifier: #6. Facility census: 79. Findings include: a) Resident #6 The medical record was reviewed on 01/09/18. [DIAGNOSES REDACTED]. physician's orders [REDACTED]. The physician also ordered [MEDICATION NAME] 5-325 mg. every twelve (12) hours as needed (prn) for pain. [MEDICATION NAME] is an opiod pain medication. Opiods block pain signals in the brain and in other parts of the central nervous system by attaching to something called mu-receptors. When opiods attach to mu-receptors in the bowel, they can cause opiod induced constipation (OIC). OIC is on of the most common side effects of opiod use, and can last for the length of treatment. Further review of physician's orders [REDACTED]. If the laxative was ineffective, the physician ordered one (1) application of Fleet enema rectally. Review of the resident's bowel movement records from 12/01/17 through 01/09/18 revealed three (3) instances where the resident went greater than three (3) days without a bowel movement, as follows: --She had a bowel movement on 12/01/17, and no evidence of another until six (6) days later on 12/07/17. --She had a bowel movement on 12/14/17, and no evidence of another until six (6) days later on 12/20/17. --She had a bowel movement on 12/30/17, and no evidence of another until five (5) days later on 01/04/18. Review of the medication administration records (MAR) for (MONTH) (YEAR) and (MONTH) (YEAR) found no evidence that Milk of Magnesia or Fleet enema was administered. Review of nurse progress notes for the time frames of 12/01/17 through 12/07/17, and 12/14/17 through 12/20/17, and 12/30/17 through 01/04/18 revealed no evidence that she had been offered a laxative, or that the lack of bowel movements for greater than three (3) days had occurred, or of any abdominal assessments and/or bowel sound assessments by nursing. Review of the care plan revealed interventions to observe for side effects of pain medication, and observe for constipation. Review of the monthly consultant pharmacist review summaries found that the pharmacist identified no irregularities in (MONTH) (YEAR) and (MONTH) (YEAR). During interview with the assistant director of nursing (ADON) on 01/09/18 at 2:00 p.m., she agreed the pharmacist initialed the Clinical Pharmacist Medication Regimen Review Summary in (MONTH) (YEAR) and (MONTH) (YEAR) that there were no pharmacy recommendations. The ADON provided copies of all the most recent consultant pharmacist recommendations to the physician, and the physician's responses. Pharmacist recommendations most recently occurred in April, August, October, and (MONTH) (YEAR). There were none for (MONTH) (YEAR) or (MONTH) (YEAR). Interviews were completed with licensed nurse #56 and registered nurse #47 on 01/10/18 at 9:24 AM. They said she is always incontinent. An interview was also completed with licensed nurse #38 on 01/10/18 at 9:24 AM. She reviewed the current MAR, then agreed the resident has no daily bowel medicine ordered. She agreed she has a prn order for Milk of Magnesia if she goes three (3) days without a bowel movement, and a Fleet enema if the Milk of Magnesia was unsuccessful. She said the resident has not received any Milk of Magnesia or Fleet enema this month, and there have been no refusals on the MAR. An interview was completed with the administrator and the director of nursing on 01/10/18 at 1:30 PM. They said they have standing orders for bowel protocol to treat on the third day if a resident has no bowel movement. No further information was provided after informing them that there was no evidence per MAR indicated [REDACTED]. The DON said the resident used to be on Senna daily, but the resident refused it. On 01/10/18 at 1:35 PM an interview was conducted with the resident. Upon inquiry, she said she sometimes has trouble with constipation. At this time, informed her that she has orders for Milk of Magnesia when needed for constipation.",2020-09-01
449,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-01-11,761,E,0,1,JURJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure medications, as well as various blood collection, intravenous flush supplies, specimen collectors and syringes were found out date (expired) or with no date to determine expiration. This had the potential to affect more than a limited number of residents. Facility census: 79. Findings include: a) Medications brought from home On 01/09/18, at 1:48 p.m., a tour of the medication room on South Hall with Licensed Practical Nurse (LPN) #3 revealed the facility had stored medications brought from home for three (3) different residents. A resident's diabetic care supplies brought from home were expired. Another bag contained additional medications brought from home for a resident. These medications included [MEDICATION NAME], Nifedpine, and Aspirin. A seperate bag contained a bottle of Jardiance10 mg (milligram) belonging to a discharged resident. LPN #3 said she felt the facility had attempted to contact the families to take these medications home. She said the faciltiy could not discard these medications because that would be considered misappropriation of property. b) Intravenous supplies found: --Eleven (11) [MEDICATION NAME] lock injections with an expiration date of 12/31/16. --Fourteen (14) [MEDICATION NAME] lock injections with an expiration date of 12/22/16. c) Expired medications found: --[MEDICATION NAME] for Resident #66 (a discharged resident). The medication was discontinued on 11/25/17. --A tube of Premethrin Cream still sealed in a tube with no expiration date d) Specimen collection devices found: --Four (4) Culture swab collection trnsport systems dated 05/17/17 --One (1) Pur Wrap Sterile Polyester Applicator dated 05/13 (applicator swab for specimen collection) --Five (5) collection transport system culture swabs --Five (5) collection swabs for [MEDICAL CONDITION] --Seven (7) collection tubes --Five (5) [MEDICATION NAME] syringes with no expiration date --68 Single use Monojet 305 [MEDICATION NAME] Injection needles --68 Ulticare 1 cc (cubic centimeter)/ml (milliliter) safety syringes with no date --Nine (9) sample selection tubes --Seven (7) Nasopharyngeal swabs dated 02/13 e) Schedule IV controlled substance --10 vials of [MEDICATION NAME] 2 mg were not secured in a permanently affixed container in the medication room refrigerator. In an interview, on 01/09/18 at 4:47 PM,with Director of Nursing (DON) #45 the DON was informed of the issues with expired medications, unsecured Schedule IV medications as well as collection tubing and specimen collectors. She indicated most of the tubing, collection devices were probably from the former company and had not been discarded as they should have been. She explained that the medications from home should have been returned to the resident's families or destroyed.",2020-09-01
450,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-01-11,791,D,0,1,JURJ11,"Based on medical record review and staff interview, the facility failed to ensure they assisted one (1) of five (5) residents in obtaining dental care. Resident #20 complained of having an issue with a tooth and was concerned about the payment. Resident identifier: #20. Facility census: 79. Findings include: a) Resident #20 On 01/08/18 at 3:37 PM, Resident #20, said a tooth in the back of her mouth on the right side was bothering her. She said she was told it would take $80.00 to see the dentist. She felt her insurance would not cover a visit to the dentist. On 01/10/18 at 9:35 AM, during an interview with Resident #20, the resident said she had told Receptionist #41 about needing to see the dentist but was not sure when she had told him. During an interview with Receptionist #41, on 01/10/18 at 9:40 AM, he said he had talked with the resident and tried to make a dental appointment for her but the resident declined the appointment because she was not sure if her insurance would cover the appointment. The resident received assistance from Medicaid. Receptionist #41 said he had not told anyone else at the facility about the resident's concerns about payment for the dental office visit. An interview with Social Worker #11 revealed she had no knowledge of the resident having requested to see a dentist or having concerns over the payment for the dental visit.",2020-09-01
451,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-01-11,842,D,0,1,JURJ11,"**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 30 residents had an accurate and complete medical record. Resident #3's diet order change was not transcribed correctly. Resident identifier: #3. Facility census: 79. Findings include: a) Resident #3 On 01/11/18 at 8:00 AM, a review of Resident #3's physician orders [REDACTED]. An interview with Dietician #74 on 01/10/18 at 8:15 AM, revealed she was not sure if the diet order was correct. Dietician #74 said that Account Manager #66 would have more information about this issue. Account Manager #66 was interviewed on 01/10/18 at 8:20 AM. He provided the diet order and communication slip dated 01/09/18 which showed the resident's diet had been upgraded to regular liquids. He reviewed the clinical physician orders [REDACTED]. He stated this was an error.",2020-09-01
452,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-01-11,880,E,0,1,JURJ11,"Based on observation and interview, the facility failed to carry out the proper infection control practices with hand washing and a tube feeding container. Resident Identifiers #43, #49, #62, #21, and #66. Facility census: 70. Findings include: a) Resident #21 Observation of a dressing change for Resident # 21, conducted on 1/10/18, at 3:28 PM, revealed that LPNf #38 failed to wash her hands after performing a treatment on a wound. When interviewed, LPN #38 stated I did not even think about it. b) Medication Administration for Residents # 43, #49, and #62 An observation of medication administration on 01/10/18 from 7:55 AM to 8:15 AM revealed Licensed Practical Nurse (LPN) #38 did not wash or sanitize their hands after each resident encounter. Resident #43, #49, and #62 were given medications during this time. An interview with LPN #38, on 01/10/18 at 8:20 AM, revealed they forgot to wash their hands during the medication administration. LPN #38 stated they got nervous but knows to always wash or use hand sanitizer after each resident during medication administration. c) Enteral Feeding for Resident #66 An observation, on 01/10/18 at 7:45 AM, revealed Resident #66's Glucerna enteral feeding container was not labeled. The container was connected to a pump and infusing into the resident. An interview with LPN #3, on 01/10/18 at 7:45 AM, revealed the nursing staff are to label enteral feeding containers when they are hung with the date, time, staff name, and flow order.",2020-09-01
454,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-11-15,583,D,0,1,T4YY12,"Based on a random observation for discovery and staff interview, the facility failed to safeguard, ensure, and maintain the privacy and confidentiality of residents' clinical records. A random observation, during a revisit survey, revealed a nurse left a computer screen unlocked and unattended, causing accessibility of all resident's electronic clinical records. This practice had the potential to affect more than a limited number of residents. Census: 85. Findings included: On 01/30/19 at 10:34 AM, this surveyor entered the nurses' station to review resident records. There was no staff in the nurses' station at the time. Several residents were gathered around the nurses' station in wheel chairs and/or strolling by, occasionally a resident wander into the nurses' station. During the revisit, residents were observed multiple times going into and out of the nurses' station. This surveyor sat down in the nurses' station to review records and a few minutes later accidentally bumped a laptop computer that was sitting on the counter. The computer screen shifted and a list of resident's names appeared on the screen. This surveyor clicked on a few names and was able to go into resident's electronic records. More than five (5) minutes past, before Licensed Practical Nurse (LPN#68) eventually returned to the nurses' station. LPN#68 was asked; if the laptop computer was the laptop from her assigned medicine cart, and what records could be accessed on it. LPN#68 confirmed it was the medicine cart's laptop computer, and that she had sat it on the counter to charge the computer's battery. LPN#68 said the medical records of all the residents could be accessed from the laptop computer. LPN#68 also verified the laptop's screen should have been locked when the LPN left the nurses' station, so that no unauthorized person could access any medical records. LPN#68 confirmed any resident or visitor could have entered the nurses' station and looked at any resident's medical records on the laptop computer while the screen was unattended and unlocked.",2020-09-01
455,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-11-15,600,D,0,1,T4YY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and staff and resident interviews, the facility failed to protect two (Resident #54 and #73) of three sampled residents from verbal and physical abuse from Resident #69. The facility census was 87. Findings include: On 11/13/18 at 4:16 PM, the clinical record for the perpetrator, Resident #69 was reviewed. Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/23/18 revealed Resident #69 was noted to have a Brief Interview for Mental Status score of 13 out of 15, indicating no impairment. The MDS revealed that Resident #69 was having no hallucinations, no verbal or other behaviors, no rejection of care. On 11/13/18 at 5:00 PM, a review of Resident #69's care plan was completed. A concern dated 03/27/18 and updated 05/27/18 noted, Socially inappropriate, yells and curses at staff and residents. Approaches were, Transfer to psych if ordered by MD, ask not to yell staff or residents, notify MD (physician) of behaviors, allow to voice concerns. Another concern, dated 08/22/18, documented, Verbally and physically abusive to staff and residents, with approaches including, Educate not to threaten other residents, ask for assistance with residents who annoy me. There was no entry on the care plan regarding where Resident #69 was to be seated in the dining room or the need for staff presence. 1. On 11/13/18 at 10:05 AM, Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) assessment, dated 10/16/18, revealed Resident #54 had a Brief Interview for Mental Status (BIMS) score of five out of 15 indicating severe cognitive impairment. The MDS indicated that Resident #54 did not exhibit physical or verbal behaviors. Review of Resident #54's care plan, dated 08/22/18, on 11/13/18 at 10:08 AM revealed a concern, I sometimes feel jealous when other residents show interest in my companion. Interventions included Please make sure I am not around other residents who have a HX (history) of aggressive behaviors. On 11/13/18 at 4:08 PM, a review of an Incident/Accident Report, dated 08/22/18, was completed. The incident report noted that Resident #69 struck Resident #54 on the arm in the dining room. The form revealed the residents were separated. An Investigation Follow-Up form also dated 08/22/18 was reviewed. Under the section Recommendations/New Interventions, Unit Manager (UM) #56 documented that Resident #54 should be kept away from residents with a known hx (history) of physical or verbal abuse. The section did not identify specific interventions or residents that Resident #54 should be kept from. Review of Progress notes dated 11/02/18 by Unit Manager #56 revealed that she was called to the dining room and found Resident #69 with his back towards the resident he attempted to strike (Resident #54). No physical contact was made, but (Resident #69) did use foul language and made threatening remarks towards (Resident #54). Plan in place to change this resident's table to another location in the dining room. (Resident #69) to be monitored closely during dining hours. No Incident/Accident report was located for the 11/02/18 incident. An interview was completed with Resident #69 on 11/12/18 at 11:01 AM. Resident #69 stated that Resident #54 hit me in the face three times in the dining room. He told me to get away from his woman. Resident #69 stated that the incident happened about a month ago and that Resident #54 has been moved away from him in the dining room. On 11/13/18 at 5:29 PM, an observation of the dining room was done. There were five rows of tables set up from left to right. Resident #69 was seated in the dining room at a table to on the first row on the left of the room. There were residents present, but no staff in the dining room. Resident #54 arrived at 5:38 and was left at a table in the center of the dining room (row 3). No staff were present from 5:39 until 5:42. On 11/13/18 at 5:59 PM, an interview was completed with the facility Social Worker (SW) #23. SW #23 said, On 08/22/18 at noon, in the dining room, there was an altercation between (Residents #69 and #54). I was notified by the former administrator that (Resident #69) struck (Resident #54) in the arm one time. There was staff in the dining room and they intervened. (Administrator #115) had (Resident #69) in her office and she had gotten a statement from him. She was telling him that under no circumstances was he to harm another resident. We put (Resident #69) on 1:1 (one staff member staying with him) and he stayed that way 24/7 until 11/01 (18). We paid a security company to sit with him. The day after we stopped the sitter (11/02/19), (Resident #69) went into the dining room and had another altercation with (Resident #54). It was verbal. (Resident #69) threatened to hit the resident. The staff intervened. An interview was completed with the facility Administrator on 11/13/18 at 6:17 PM. When (Resident #69) is in the dining room, staff know to keep them separated. (Resident #69) is on the one side of the dining room and (Resident #54) is on the far opposite side. There is always staff in the dining room when residents are in there. The Administrator said the residents were seated at rows as far apart as they can be. When (Resident #69) is in his bed or his room, he can't move himself so there is no danger. An interview was completed with Resident #54 on 11/13/18 at 7:26 PM. Resident #54 said, He (Resident #69) started on me. I don't know why. He hit me on the wrist. I didn't hit him back. Resident #54 said that there were no issues with Resident #69 before the incident. Resident #54 said there was a second incident He said he would hurt me. We were in the dining room. Resident #54 also said that he still sees Resident #69 in the dining room when they are eating meals, but he doesn't look at me and I don't look at him. On 11/14/18 at 10:00 AM, an interview was completed with Certified Nurse Aide (CNA) #73. CNA #73 stated that she was familiar with Resident #54 and that she had heard about the incident involving Resident #54 and #69 on 08/22/18. Some of the staff had to separate them in the dining room after (Resident #69) hit (Resident #54). No one said specifically not to leave him in the dining room without staff. An interview was completed with Unit Manager (UM) #56 on 11/14/18 at 2:19 PM. UM #56 stated that she was familiar with Resident #69 and #54. (Resident #69) can move himself in his wheelchair. Not very far, but he can. The second time (11/02/18), there wasn't any contact. (Resident #68) was yelling at (Resident #54) with his good arm raised. They (staff) came and got me and I went to the dining room and I moved the table where (Resident #69) sat. When I went in, (Resident #69) was facing (Resident #54) in the wheelchairs. (Resident #69)'s hand was up, but there was no striking. All I did was change the table where he sits. There is always staff in there when they are in the dining room to keep an eye on them. 2. On 11/15/18 at 8:15 AM, the clinical record for Resident #73 was reviewed. Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/15/18 at 8:15 AM, a review of the 14-day Minimum Data Set assessment dated [DATE] was completed. Resident #73 was noted to have a BIMS score of 15 out of 15, indicting no cognitive impairment. Resident #73 had no noted deficiency with her hearing. Her speech was unclear and was slurred or mumbled. She usually understood others and comprehends most of the conversation. On 11/14/18 at 10:00 AM, an interview was completed with Certified Nurse Aide (CNA) #73. CNA #73 stated that she was familiar with Residents #69 and #73. She stated, Resident #69 doesn't like her (Resident #73). He calls her a princess and says she is brain dead and things. He repeats the way she talks, and she heard him (Resident #69) and she cried. CNA #73 said that she witnessed Resident #69 calling Resident #73 names from his room while she was working with Resident #73 She stated that Resident #73 was upset and crying. I told the old administrator (Administrator #115) maybe 2 months ago. Administrator #115 is no longer employed at the facility. The Administrator and the SW were asked on multiple occasions during the survey if there was documentation on investigating or reporting the incident. No Progress Notes, Investigations or State reports were located regarding any incidents between Resident #69 and Resident #73. On 11/14/18 at 11:05 AM, an interview was completed with Social Worker (SW) #23. SW #23 said, (Resident #69) told us that (Resident #73) needs more assistance than he does and that bothers him. He called her names to us, but not to her. Resident #73 hasn't reported anything about him. On 11/14/18 at 1:32 PM, an interview was completed with Resident #73. Resident #73 used a spelling board with the help of staff to communicate. CNA #73 assisted with the interview. Resident #73 reported that she was having problems with Resident #69. Resident #69 said something to her. He called her names. Last night she and Resident #69 were waiting to lie down. He said, 'Oh great, the princess first.' He has called me braindead. Resident #73 stated that this was not witnessed by staff. Resident #73 said the comments made her cry in the past. She also said that Resident #69 has made fun of how she talks. Sometimes he makes loud comments from his room that she can hear and sometimes it is when she can see him. Resident #73's room is located across the hall from Resident #69. On 11/14/18 at 1:57 PM, another interview was completed with Resident #69. I've not had any problem with (Resident #73). I've had a problem with the people who care for her. I have to wait every time for them to help me while they help her. Every time she makes a grunt, they run to her. I'm sure I've said that a time or two. I don't talk to her. To the staff I call her the queen because she has to go first. She knows my voice.",2020-09-01
456,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-11-15,609,D,0,1,T4YY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, abuse policy review and staff interviews, the facility failed to report to the state agency allegations of or suspected abuse for two (Residents #73 and #24) of three sampled residents reviewed for allegations of abuse. The facility census was 87. Findings include: 1. Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/15/18 at 8:15 AM, a review of the 14-day Minimum Data Set (MDS) was completed. Resident #73 was noted to have a BIMS score of 15 out of 15 indicating no cognitive impairment. No State reports were located regarding any incidents between Resident #69 and Resident #73. Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS, dated [DATE], was completed on 11/13/18 at 4:16 PM. Resident #69 was noted to have a BIMS score of 13 out of 15, indicating minimal cognitive impairment. The MDS revealed that Resident #69 was having no hallucinations, no verbal or other behaviors, no rejection of care. On 11/14/18 at 10:00 AM, an interview was completed with Certified Nursing Aide (CNA) #73. CNA #73 stated that she was familiar with residents #69 and 73. (Resident #69) doesn't like (Resident #73). He calls her a princess and says she is brain dead and things. He repeated the way she talks, and she heard him and she cried. CNA #73 said that she witnessed Resident #69 calling Resident #73 names from his room while she was working with Resident #73, and that Resident #73 was upset and crying. I told the old administrator (Administrator #115) maybe 2 months ago. Administrator #115 was no longer employed at the facility. CNA #73 said that she was not specifically told not to leave Resident #69 him in the dining room without staff, but there was always staff in there to watch residents. On 11/14/18 at 11:05 AM, a follow up interview was completed with SW #23. SW #23 said, If there is an injury, we would report it. I can report, the DON and the Administrator can report. The State regulations are what we follow. It says if there isn't an injury, it doesn't have to be reported. (Resident #69) told us that (Resident #73) needs more assistance than he does and that bothers him. He called her names to us, but not to her. She hasn't reported anything about him. On 11/14/18 at 1:32 PM, an interview was completed with Resident #73. Resident #73 uses a spelling board with the help of staff to communicate. CNA #73 assisted with the interview. Resident #73 reported that she was having problems with Resident #69. Resident #69 said something to her. He called her names. Last night she and Resident #69 were waiting to lay down (both need staff assistance with a mechanical lift to transfer), He said, 'oh great the princess first.' He has called me braindead. Resident #73 stated that this was not witnessed by staff. Resident #73 said that the comments made her cry in the past. She also said that Resident #69 has made fun of how she talks. I get up first, so I think I should go down first. Sometimes he makes loud comments from his room that she can hear and sometimes it is when she can see him. On 11/14/18 at 1:57 PM, another interview was completed with Resident #69. I've not had any problem with (Resident #73). I've had a problem with the people who care for her. I have to wait every time for them to help me while they help her. Every time she makes a grunt, they run to her. I'm sure I've said that a time or two. I don't talk to her. To the staff I call her the queen because she has to go first. She knows my voice. 2. Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was noted to wander daily. A review of Resident #24's care plan was completed on 11/15/18 at 8:32 AM. On 09/26/18 a concern was noted to be, I occasionally wheel myself in my wheelchair to male residents asking them to kiss me. I mistake them for my husband. Approaches included Explain to the male residents who I approach that I sometimes mistake them for my husband and Redirect me by offering me coffee, snack, activities, etc. On 06/28/18, the care plan was updated to note a concern titled, I wander the facility in my wheelchair daily, going into other resident's rooms, into offices, etc. Approaches included Monitor my whereabouts at all times. No State reports were located regarding an incident between Resident #69 and Resident #24. On 11/13/18 at 5:00 PM, a review of Resident #69's care plan was completed. On 08/23/18, under Interventions, a note was added I kissed a female resident who lacks capacity and who has severely impaired memory and decision making. Educate me that I am not to do this. An interview was completed with SW#23 on 11/13/18 at 6:20 PM. There was an incident with a female resident (Resident #24). She doesn't have capacity to know what she is doing. She went up to (Resident #69) in the dining room in her wheelchair and asked him to kiss her and he did. Someone (didn't remember who) came and reported it to me. They (Residents #69 and #54 were separated. The former Administrator (#115) was aware of the incident. SW #23 said that she was unable to find an incident investigation, or any report submitted to the State. On 11/14/18 at 9:28 AM, an interview was completed with the Administrator. The Administrator said that he was trying to get in touch with the old administrator to see if she did an investigation or if she reported it and that he could not find any documentation of the incident with Resident #24. Another interview was completed with Resident #69 on 11/14/18 at 9:32 AM. Resident #69 said that he can move himself in the wheel chair some. When asked about the incident involving Resident #24, Resident #69 said, A lady kissed me in the dining. She was coming in the dining room and I was going out. I had talked to her before. We were talking. She was confused that I was her husband. She held my hand first and there was some chit chat. Then she kissed me on the lips. Resident #69 stated that he kissed Resident #24 back. When we were talking, I could tell she was confused. I knew I wasn't her husband. I wouldn't know her since my sight has gotten worse. On 11/14/18 at 10:39 AM, a follow up interview was completed with the Administrator. I talked to the former Administrator and the interim DON who was here during the incident with the kissing. They didn't recall doing an investigation and I haven't been able to find any documentation in our files. The administrator stated that he couldn't say if the incident involving Resident #24 was required to be reported, but that he would have. On 11/14/18 at 11:05 AM, a follow up interview was completed with SW #23. SW #23 said, If there is an injury, we would report it. I can report, the DON and the Administrator can report. The State regulations are what we follow. It says if there isn't an injury, it doesn't have to be reported. (Resident #24) was the resident (Resident #69) kissed. I was not part of investigating that. I was with the Administrator (Administrator #115) when she talked to him about that. SW#23 stated the incident happened before an incident with Resident #54, but she wasn't sure what day. If the kissing was abusive towards the resident, it would be reported. We would ask her general questions. She has a care plan because she mistakes residents for her husband. She doesn't have capacity. We would watch her for anxiety (to know if the kissing affected Resident #24). On 11/14/18 at 4:02 PM, an interview was completed with the Director of Nurses (DON). The DON said that if there was an abuse allegation, The nurse or I do an incident report and notify the physician. An S-bar gets done (situation back round assessment and response) by the person doing the incident report. The staff would notify me of the allegation. The social worker, unit manager, Administrator and DON would do an investigation. We would notify the ombudsman and OFLAC (State agency). The social worker would usually do the 24 hour and the 5-day report. We report allegations of abuse or neglect, physical abuse if there is harm. If the person feels scared or threatened, it's still reportable. We report misappropriation of items and allegations of sexual abuse. If a resident makes an allegation that he was struck by a resident, it is reportable. I don't know of anyone else (besides Resident #54) who (Resident #69) says bothers him or any resident who complains about (Resident #69). Review of the facility policy titled Abuse and Neglect Prohibition, dated (MONTH) (YEAR), was completed on 11/14/18 at 6:15 PM. Under Investigation, the policy stated, The facility will timely conduct an investigation of any alleged abuse/neglect, exploitation . in accordance with state law. Under the section titled Reporting and Response, the policy stated, The facility will report all allegations and substantiated concerns of abuse, neglect . to the administrator, State Survey Agency . in accordance with Federal and State law. a. If the events that caused the allegation involve abuse or result in serious bodily injury, a report is made not later than 2 hours after the management staff becomes aware of the allegation.",2020-09-01
457,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-11-15,610,D,0,1,T4YY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to investigate allegations of abuse for two (Resident #54 and #73) of three sampled residents reviewed for allegations of abuse from Resident #69. The facility census was 87. Findings include: 1. Review of the 11/15/18 at 8:15 AM, Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/15/18 at 8:15 AM, a review of the 14-day Minimum Data Set (MDS) was completed. Resident #73 was noted to have a BIMS score of 15 out of 15 indicting no cognitive impairment. No Progress Notes, Investigations or State reports were located regarding any incidents between Resident #69 and Resident #73. Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] was completed on 11/13/18 at 4:16 PM. Resident #69 was noted to have a BIMS score of 13 out of 15, indicating minimal cognitive impairment. On 11/14/18 at 10:00 AM, an interview was completed with Certified Nursing Aide (CNA) #73. CNA #73 stated that she was familiar with residents #69 and #73. (Resident #69) doesn't like (Resident #73). He calls her a princess and says she is brain dead and things. He repeated the way she talks, and she heard him and she cried. CNA #73 said that she witnessed Resident #69 calling Resident #73 names from his room while she was working with Resident #73, and that Resident #73 was upset and crying. I told the old administrator (Administrator #115) maybe 2 months ago. Administrator #115 is no longer employed at the facility. CNA #73 said that she was not specifically told not to leave Resident #69 in the dining room without staff, but there was always staff in there to watch residents. On 11/14/18 at 11:05 AM, a follow up interview was completed with SW #23. SW #23 said, If there is an injury, we would report it. I can report, the DON and the Administrator can report. The State regulations are what we follow. It says if there isn't an injury, it doesn't have to be reported. (Resident #69) told us that (Resident #73) needs more assistance than he does and that bothers him. He called her names to us, but not to her. She hasn't reported anything about him. On 11/14/18 at 1:32 PM, an interview was completed with Resident #73. Resident #73 used a spelling board with the help of staff to communicate. CNA #73 assisted with the interview. Resident #73 reported that she was having problems with Resident #69. Resident #69 said something to her. He called her names. Last night she and Resident #69 were waiting to lay down (both need staff assistance with a mechanical lift to transfer), He said, 'Oh great the princess first.' He has called me braindead. Resident #73 stated that this was not witnessed by staff. Resident #73 said that the comments made her cry in the past. She also said that Resident #69 has made fun of how she talks. I get up first, so I think I should go down first. Sometimes he makes loud comments from his room that she can hear and sometimes it is when she can see him. Resident #73's room is across the hall from Resident #69. On 11/14/18 at 1:57 PM, another interview was completed with Resident #69. I've not had any problem with (Resident #73). I've had a problem with the people who care for her. I have to wait every time for them to help me while they help her. Every time she makes a grunt, they run to her. I'm sure I've said that a time or two. I don't talk to her. To the staff I call her the queen because she has to go first. She knows my voice. On 11/14/18 at 4:02 PM, an interview was completed with the Director of Nurses (DON). The DON said that if there was an abuse allegation, The nurse or I do an incident report and notify the physician. An S-bar gets done (situation back round assessment and response) by the person doing the incident report. The staff would notify me of the allegation. The social worker, unit manager, Administrator and DON would do an investigation. We would notify the ombudsman and OFLAC (State agency). The social worker would usually do the 24 hour and the 5 day report. We report allegations of abuse or neglect, physical abuse if there is harm. If the person feels scared or threatened, it's still reportable. We report misappropriation of items and allegations of sexual abuse. If a resident makes an allegation that he was struck by a resident, it is reportable. I don't know of anyone else (besides Resident #54) who (Resident #69) says bothers him or any resident who complains about (Resident #69). 2. Resident #24 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. She was noted to wander daily. A review of Resident #24's care plan was completed on 11/15/18 at 8:32 AM. On 09/26/18 a concern was noted to be, I occasionally wheel myself in my wheelchair to male residents asking them to kiss me. I mistake them for my husband. Approaches included Explain to the male residents who I approach that I sometimes mistake them for my husband and Redirect me by offering me coffee, snack, activities, etc. On 06/28/18, the care plan was updated to note a concern titled, I wander the facility in my wheelchair daily, going into other resident's rooms, into offices, etc. Approaches included Monitor my whereabouts at all times. No Progress notes, incident reports or State reports were located regarding an incident between Resident #69 and Resident #24. An interview was completed with SW#23 on 11/13/18 at 6:20 PM. There was an incident with a female resident (Resident #24). She doesn't have capacity to know what she is doing. She went up to (Resident #69) in the dining room in her wheelchair and asked him to kiss her and he did. Someone (didn't remember who) came and reported it to me. They (Residents #69 and #54 were separated. The former Administrator (#115) was aware of the incident. SW #23 said that she was unable to find an incident investigation. On 11/14/18 at 9:28 AM, an interview was completed with the Administrator. The Administrator said that he was trying to get in touch with the old administrator to see if she did an investigation or if she reported it and that he could not find any documentation of the incident with Resident #24. Another interview was completed with Resident #69 on 11/14/18 at 9:32 AM. Resident #69 said that he can move himself in the wheel chair some. When asked about the incident involving Resident #24, Resident #69 said, A lady kissed me in the dining. She was coming in the dining room and I was going out. I had talked to her before. We were talking. She was confused that I was her husband. She held my hand first and there was some chit chat. Then she kissed me on the lips. Resident #69 stated that he kissed Resident #24 back. When we were talking, I could tell she was confused. I knew I wasn't her husband. I wouldn't know her since my sight has gotten worse. On 11/14/18 at 10:39 AM, a follow up interview was completed with the Administrator. I talked to the former Administrator and the interim DON who was here during the incident with the kissing. They didn't recall doing an investigation and I haven't been able to find any documentation in our files. The administrator stated that he couldn't say if the incident involving Resident #24 was required to be reported, but that he would have. On 11/14/18 at 11:05 AM, a follow up interview was completed with SW #23. SW #23 said, I was not part of investigating that. I was with the Administrator (Administrator #115) when she talked to him about that. SW#23 stated the incident happened before an incident with Resident #54, but she wasn't sure what day. If the kissing was abusive towards the resident, it would be reported. We would ask her general questions. She has a care plan because she mistakes residents for her husband. She doesn't have capacity. We would watch her for anxiety (to know if the kissing affected Resident #24). Review of the facility policy titled Abuse and Neglect Prohibition dated (MONTH) (YEAR) was completed on 11/14/18 at 6:15 PM. Under Investigation, the policy notes The facility will timely conduct an investigation of any alleged abuse/neglect, exploitation . in accordance with state law.",2020-09-01
458,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-11-15,684,J,0,1,T4YY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and facility policy review, the facility failed to ensure two (Resident #48 and #32) of two sampled residents were provided appropriate care and services related to standards of practice and competency for Intravenous (IV) therapy resulting in Immediate Jeopardy. The facility census was 87. On 11/13/18 at 7:56 PM, the Administrator and Director of Nursing were notified verbally that Immediate Jeopardy began on 10/05/18, when Resident #48 was readmitted with a peripheral inserted central catheter (PICC) for IV therapy. Licensed Practical Nurses (LPNs) #27, #33, #49 and #59 performed IV therapy without sufficient training and verification of such. The Immediate Jeopardy continued when Resident #32 was re-admitted to the facility on [DATE] with a PICC line in her right arm for intravenous antibiotic therapy. LPNs #6, #20, #35, #39 and #64 performed IV therapy for Resident #32 without sufficient training and verification of competency. Immediate Jeopardy was abated on 11/13/18 at 8:10 PM. The facility completed an assessment of Resident #48 and Resident #32 to identify any adverse effects related to IV therapy. The facility revised the staffing schedule to ensure a Registered Nurse would be performing IV therapy for the two residents (Resident #48 and #32) and any newly admitted residents with IV access. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a 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 F883 (Facility Assessment), F867 (Quality Assurance and Performance Improvement program) and F726 (Staff Competency) for additional information. Findings include: 1. A comprehensive chart review for Resident #48 was conducted on 11/13/18 at 2:00 PM and noted the following information. The Admission Record identified Resident #48 was originally admitted to the facility on [DATE] with a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #48's hospital Discharge Summary dated 10/05/18 revealed Resident #48 had a peripherally inserted central catheter (PICC) line in her right upper arm. 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, and for blood draws, which is considered IV therapy. The referring physician's orders on the discharge summary included [MEDICATION NAME] (an antibiotic) 1250 mg intravenously once per day for two weeks. Continued review of the clinical record on 11/14/18 at 9:00 AM, revealed an Admission Note dated 10/05/18 that stated Resident #48 had a PICC line to right upper arm upon admission back to the facility. A quarterly Minimum Data (MDS) assessment dated [DATE], revealed Section C for cognition a Brief Interview for Mental Status (BIMS) test scored Resident #48 as 11 out of 15 which indicated the resident had moderately impaired cognition. Section N0410 subsection F received antibiotic medication for 7 days during the assessment period. Section O Subsection H received intravenous therapy during the assessment period. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. LPNs #27, #33, and #59 were documented as administering the antibiotic medication. The clinical record from 10/20/18 thru 10/26/18 did not include an order to flush the PICC line with normal saline 10cc every shift to ensure patency until 10/31/18. Review of a physician order dated 10/27/18, the physician ordered [MEDICATION NAME] (a medication to dissolve a blood clot) 5 units via PICC line due to an occlusion. The Nursing Progress Notes did not include a nursing assessment regarding the PICC line being occluded on 10/27/18 which required the use of [MEDICATION NAME] to dissolve the blood clot. On 10/31/18, Resident #48's physician again ordered [MEDICATION NAME] 1250 mg intravenously once per day for 6 weeks and to flush the PICC line with normal saline 10cc every shift to ensure patency. The intravenous antibiotic medication was documented as completed daily from 10/31/18 through 11/13/18 by the administering nurses. LPNs #27, #33, #48 and #59 were documented as flushing and/or administering the IV antibiotic medication. A plan of care dated 11/03/18 included the Focus of I receive IV antibiotic therapy r/t (related to) [MEDICAL CONDITION]. The interventions included provide PICC line care as ordered. During an observation on 11/13/18 at 4:00 PM, LPN #27 was observed entering Resident #48's room. LPN #27 was preparing to disconnect the [MEDICATION NAME] pump. An [MEDICATION NAME] pump is a device that infuses intravenous medication once the tubing is unclamped. The device pushes intravenous medication through the tubing and a filter that is attached to the pump reservoir. LPN #27 had a syringe with normal saline and was preparing to disconnect the [MEDICATION NAME] pump and flush the PICC line with 10 ccs of normal saline as ordered by the physician. The surveyor intervened and queried LPN #27 on her training to ensure proper care and services regarding use of a PICC line for medication administration. She stated she had received training from the facility regarding care and services required for a PICC line. When queried further about the difference between a PICC line and other peripherally inserted IVs, she stated, it's just higher up on the arm. When queried on adverse reactions that can occur with a PICC line, she stated redness, swelling and hot to touch. LPN #27 did not include the life threatening adverse reactions of blood clots and [MEDICAL CONDITION] embolism. During an interview conducted on 11/14/18 at 1:10 PM, Unit Manager RN #29 verified on 10/27/18, Resident #48's PICC line was occluded by the formation of a blood clot and required the use of [MEDICATION NAME] to dissolve the blood clot. Unit Manger #29 stated the standard of practice to ensure PICC line patency was to flush the PICC line every shift with 10 cc of normal saline. She verified there was not a physician order for [REDACTED]. During an interview conducted on 11/15/18 at 11:31 AM, Unit Manager RN #29 stated she had been employed by facility for approximately one year and does not remember receiving training on the facility policy for intravenous therapy nor remembers being assessed for competency for intravenous therapy. In addition, at 12:06 PM, RN #29 was queried if she received training regarding scope of practice for LPNs regarding intravenous therapy. Unit Manager RN #29 stated, No. During an interview conducted on 11/14/18 at 11:35 AM, LPN #49 stated being employed at the facility for approximately three months. When queried about type of training he received regarding IV therapy he stated, I watched a 5-minute video on IV therapy and received a 4-5-page handout. When asked if he felt confident in his skill set for intravenous administration of medication he stated, yes since the IV medication was in a ball type device that delivered the medication. When queried about being assessed for competency, he stated the previous education nurse watched him perform IV therapy; however, he could not remember when the evaluation occurred. LPN #49 verified he had been administering medications to Resident #48. During an interview conducted 11/14/18 at 11:45 AM, LPN #33 stated being employed at the facility since (MONTH) (YEAR). She verified she had not received training on intravenous therapy including care of a resident with a PICC line. She stated she had not received training on how to administer medications via a PICC line nor had anyone at the facility verified her competency to care for a resident with a PICC line. She verified she had been administering medication via a PICC line to Resident #48. 2. A focused chart review for Resident #32 was conducted on 11/15/18 at 9:00 AM. The following was reviewed related to Resident #32 receiving intravenous therapy through a PICC line. The Admission Record identified Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data (MDS) assessment dated [DATE], revealed Section C for cognition a Brief Interview for Mental Status (BIMS) test scored Resident #48 as 11 out of 15 which indicated the resident had moderately impaired cognition. Review of Progress Notes revealed readmission physician orders dated 10/05/18 that included [MEDICATION NAME] (an antibiotic) 2 GM (grams) intravenously every 4 hours until 12/16/18 for infection of the craniotomy incision line. A care plan dated 11/02/18 revealed a Focus of, I have a post op infection of my craniotomy incision and require IV antibiotics through a PICC line. The interventions included, Provide PICC line care per facility protocol. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. LPN's #6, #20, #35, #39 and #64 were documented as flushing the PICC line and/or administering the IV antibiotic medication. During an interview conducted on 11/14/18 at 11:35 AM, LPN #49 stated he was employed at facility for approximately three months. When queried about type of training he received regarding IV therapy he stated, I watched a 5-minute video on IV therapy and received a 4-5-page handout. When asked if he felt confident in his skill set for intravenous administration of medication he stated yes since the IV medication was in a ball type device that delivered the medication. When queried about being assessed for competency, he stated the previous education nurse watched him perform IV therapy; however, he could not remember when the evaluation occurred. LPN #49 verified he had been administering medications to Resident #32. During an interview conducted on 11/14/18 at 11:55 AM, LPN #6 stated being employed at the facility for approximately [AGE] years. She stated she received intravenous therapy training around [AGE] years ago. She stated the facility provided a one-hour intravenous therapy training approximately 6 months ago. She stated the training did not include a competency assessment to ensure an adequate skill set to care for residents receiving intravenous therapy through a PICC line. She verified she had administered IV medication to Resident #32 via a PICC line. Review of the facility policy and procedure Catheter Insertion and Care Flushing Midline and Central Line IV Catheters dated 05/12 revealed Midline and Central Line IV catheters ([MEDICAL CONDITION]) will be flushed to maintain patency and to ensure entire dose of solution or medication is administered into the venous system. Flushing protocol: 1. Flush catheters at regular intervals to maintain patency and before and after administration of medication. 2. Each lumen of a catheter is a separate catheter. Each lumen must be flushed at least every 24 hours to prevent occlusion. Some catheters (per manufacturers guidelines or organizational policy) may need to be flushed more often. Review of Power PICC SOLO manufacturers guidelines Recommended Flushing/Maintenance Procedure(s): The catheter should be maintained in accordance with standard hospital protocols. Recommended catheter flushing/maintenance is as follows: 1. Flush the catheter after every use, or at least weekly when not in use. Review of the facility policy and procedure Peripherally inserted central catheter (PICC) drug administration dated (MONTH) 18, (YEAR) included Critical Notes! Note: PICC Line procedures may only be conducted by Licensed Nurse with appropriate training.",2020-09-01
459,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-11-15,688,D,0,1,T4YY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and observation, the facility failed to ensure that a resident with limited range of motion received the prescribed services and equipment to maintain or improve mobility. This affected one out of one resident (Resident #36) with limited range of motion (ROM) reviewed. Resident #36 was prescribed knee extension braces to prevent further contractures of her knees. The facility census was 87. Findings include: Review of the clinical record on 11/15/18 at 8:49 AM revealed an admission history form dated 08/08/14. The admission history documented that Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 10/05/18, documented Resident #36 was completely dependent on two staff for her Activities of Daily Living (ADLs) and had limited range of motion in both of her knees. The clinical record documented a physician's orders [REDACTED]. The Plan of Care (P[NAME]) for impaired mobility, dated 04/16/18 documented to apply bilateral knee extension devices in bed. The nurse aide care plan documented to apply bilateral knee extension devices in bed. On 11/15/18 at 9:08 AM, Resident #36 was observed up in her wheelchair. The bilateral knee extension braces were not observed to be in Resident #36's room. On 11/15/18 at 9:10 AM, Certified Nursing Assistant (CNA) #12 was interviewed. CNA #12 stated that she had been working with Resident #36 for about a month and she was not aware of any knee extension braces that were to be applied while in bed. On 11/15/18 at 9:15 AM, Director of Rehabilitation Services (DOR) #75 was interviewed. DOR #75 stated that when Resident #36 was discharged from Physical Therapy in (MONTH) of (YEAR), Physical Therapy asked for an order for [REDACTED]. DOR #75 was going to demonstrate what the knee extension braces looked like but was only able to locate one brace in Resident #36's room. It was observed on top of the closet. On 11/15/18 at 9:45 AM, the physical therapy discharge summary, dated 03/23/18 was reviewed. The discharge plan documented, in part, for nursing to continue to use positioning devices while in bed. The quarterly physical therapy screening forms were reviewed. The forms were dated 02/02/18, 04/04/18, 07/11/18 and 10/08/18. Each form documented that there had been no changes to Resident #36's range of motion and to continue to use the knee extension braces while Resident #36 was in bed. On 11/15/18 at 9:50 AM a Restorative Nursing program form dated 09/20/18 was reviewed. The form documented a training between Occupational Therapist (OT) #79 and CNAs #15, CNA #68 and CNA #24. The training was specific to Resident #36 in regard to proper positioning while up in her wheelchair and for the knee extension splints while in bed. On 11/15/18 at 4:07 PM, Resident #36 was observed to be lying in bed. The knee extension braces were not applied or visible in her room. On 11/15/18 at 4:23 PM, CNA #24 was interviewed. CNA #24 stated that I've never seen those things (the knee extension braces) and I work with Resident #36 every day that I am here.",2020-09-01
460,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-11-15,726,K,0,1,T4YY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, policy review, training documentation and review of the State Board of Examiners for Licensed Practical Nurses, the facility failed to ensure Licensed Practical Nurses (LPN) were trained and competent to perform Intravenous (IV) therapy including administration of medications via a peripheral inserted central catheter (PICC) within their scope of practice and state regulations. The facility was unable to provide verification of sufficient IV training and competency for nine (#6, #20, #27, #33, #35, #39, #49, #59 and #64) of nine LPNs who were performing IV therapy. This practice resulted in Immediate Jeopardy. The facility census was 87. On 11/13/18 at 7:56 PM, the Administrator and Director of Nursing were notified verbally that Immediate Jeopardy began on 10/05/18 when Resident #48 was readmitted to the facility with a peripheral inserted central catheter (PICC) and receiving IV therapy. The Immediate Jeopardy continued when Resident #32 was re-admitted to the facility on [DATE] with a PICC line in her right arm for intravenous antibiotic therapy. LPN's #27, #33, #49 and #59 performed IV therapy for Resident #48 and LPNs #6, #20, #39, #49 and #64 performed IV therapy for Resident #32 without sufficient training and competency. Immediate Jeopardy was abated on 11/13/18 at 8:10 PM. The facility completed an assessment of Resident #48 and Resident #32 to identify any adverse effects related to IV therapy. The facility revised the staffing schedule to ensure an Registered Nurse would be performing IV therapy for the two residents and any newly admitted residents with IV access. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a 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. See F684 (Quality of Care) regarding Resident #48 and #32. See F883 (Facility Assessment) and F867 (Quality Assurance and Performance Improvement program) for additional information. Findings include: During an observation on 11/13/18 at 4:00 PM, LPN #27 was observed entering Resident #48's room. LPN #27 was preparing to disconnect the [MEDICATION NAME] pump. An [MEDICATION NAME] pump is a device that infuses intravenous medication once the tubing is unclamped. The device pushes intravenous medication through the tubing and a filter that is attached to the reservoir. LPN #27 had a syringe with normal saline and was preparing to disconnect the [MEDICATION NAME] pump and flush the PICC line with 10 cubic centimeters (ccs) of normal saline as ordered by the physician. 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, and for blood draws, which is considered IV therapy. The surveyor intervened prior to the administration and queried LPN #27 on her training to ensure proper care and services regarding medication administration via a PICC line. She stated she had received training from the facility regarding care and services required for a PICC line. When queried further about the difference between a PICC line and other peripherally inserted IVs, she stated, it's just higher up on the arm. When queried on adverse reactions that can occur with a PICC line, LPN #27 stated redness, swelling and hot to touch. LPN #27 did not include the life threatening adverse reactions of blood clots and [MEDICAL CONDITION] embolism. During an interview conducted on 11/14/18 at 11:35 AM, LPN #49 stated he was employed at facility for approximately three months. When queried about type of training he received regarding IV therapy he stated, I watched a 5-minute video on IV therapy and received a 4-5-page handout. When asked if he felt confident in his skill set for intravenous administration of medication, he stated yes since the IV medication was in a ball type device that delivered the medication. When queried about being assessed for competency, he stated the previous education nurse watched him perform IV therapy; however, he could not remember when the evaluation occurred. LPN #49 verified he had been administering IV medications via a PICC to Resident #48 and Resident #32. During an interview conducted 11/14/18 at 11:45 AM, LPN #33 stated being employed at the facility since (MONTH) (YEAR). She verified she had not received training on intravenous therapy including care of a resident with a PICC line. She stated she had not been provided training on how to administer medications via a PICC line nor had anyone at the facility verified her competency to care for a resident with a PICC line. She verified she had been administering medication via a PICC line to Resident #48. During an interview conducted on 11/14/18 at 11:55 AM, LPN #6 stated being employed at facility for approximately [AGE] years. She stated she received intravenous therapy training around [AGE] years ago. She stated the facility provided a one-hour intravenous therapy training approximately 6 months ago. She stated the training did not include a competency assessment to ensure an adequate skill set to care for residents receiving intravenous therapy through a PICC line. She verified she had administered IV medication to Resident #32 via a PICC line. During an interview conducted on 11/15/18 at 11:31 AM, Unit Manager RN #29 stated she had been employed by facility for approximately one year and does not remember receiving training on the facility policy for intravenous therapy nor remembers being assessed for competency for intravenous therapy. In addition, at 12:06 PM on 11/15/18, Unit Manager #29 was queried if she received training regarding scope of practice for License Practical Nurses regarding intravenous therapy. Unit Manager RN #29 stated No. A Training Attendance document dated 07/05/17 titled IV Certification with a duration of 1-hour was reviewed. LPN #27 and #6 were in attendance. The training content was reviewed and it did not contain information specific to care and services for a PICC line and the use of an [MEDICATION NAME] pump to administer intravenous antibiotics. During an interview conducted on 11/14/18 at 1:15 PM, District Director of Clinical Resources RN #112 produced a competency checklist for LPN #33 dated for 11/13/18. She stated the competency check was conducted yesterday by Staff Development Manager RN #5. She further verified the training material used by the facility during new employee orientation and the Licensed Nurse Competency Checklist did specifically include care for a resident with a PICC line. In addition, she verified the training material for the IV Certification conducted on 07/05/17 did not include content for the care of residents receiving intravenous medications through a PICC line. During an interview conducted on 11/14/18 at 1:30 PM, Staff Development Manger RN #5 stated she verified LPN #33's competency on 11/13/18 by having her repeat back to her how to care for a resident with a PICC line which included how to administer medications. During an interview conducted on 11/14/18 at 11:45 AM, District Director of Clinical Resources #112 stated in order to ensure nurse competency in caring for a resident receiving medications through a PICC line, the LPN should be observed performing the skill. She stated having the nurse repeat verbally the steps would not be sufficient to ensure competency. In addition, during the interview, a request was made for training documentation for LPN's #20, #35, #39, #49, #59 and #64. District Director of Clinical Resources #112 was unable to provide documentation of LPN training and verification of competency related to care and services for a resident with a PICC line prior to the time of date and time of exit. Review of the facility policy and procedure Peripherally inserted central catheter (PICC) drug administration dated (MONTH) 18, (YEAR) included Critical Notes! Note: PICC Line procedures may only be conducted by a Licensed Nurse with appropriate training. Review of APPENDIX B of the WEST VIRGINIA STATE BOARD OF EXAMINERS FOR LICENSED PRACTICAL NURSES revealed a statement originally issued in June, 1977. The statement indicated the administration of I.V. fluids is not a part of the standard curriculum for accredited schools of practical nursing in West Virginia. However, if additional training has been received and can be verified, providing there is adequate supervision and the licensed practical nurse is willing to accept responsibility, it is not illegal for a licensed practical nurse to perform administration of I.V. fluids.",2020-09-01
461,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-11-15,758,D,0,1,T4YY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to complete a gradual dose reduction of [MEDICATION NAME] (an anti-psychotic) as ordered by the physician. This affected one (Resident #15) of five sampled residents reviewed for unnecessary medications. The facility census was 87. Findings included: Review of the clinical record on 11/15/18 at 10:28 AM revealed an admission history form dated 03/14/16. The admission history documented Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 09/16/18, documented a Brief Interview for Mental Status (BIMS) score of nine out of 15, a moderate memory impairment. The MDS documented that Resident #15 was often sleepy and had little energy. The MDS assessed for [MEDICAL CONDITION] and hallucinations and no episodes were documented. The MDS documented that Resident #15 needed extensive assistance of one person to complete her activities of daily living (ADLs). Resident #15 had a plan of care (P[NAME]), dated 04/19/17, that documented dementia with behaviors as exhibited by verbal and physical behaviors towards staff that included hitting, kicking, and using foul language. A P[NAME] intervention, dated 04/20/18, was to do a gradual dose reduction (GDR) of her medications as tolerated. Per the form entitled Note to Attending Physician/ Prescriber, dated 02/08/18, the facility's pharmacist recommended that Resident #15's [MEDICATION NAME] be reduced from 25 mg tablet one time per day to 12.5 mg tablet one time per day because there was no documented behaviors on (the behavior) monitor sheets. On 02/13/18 a physician's orders [REDACTED]. During the clinical record review, no evidence was documented that the physician order [REDACTED]. Review of the physician order [REDACTED].#15 was still taking [MEDICATION NAME] 25 mg one time per day. On 11/15/18 at 12:09 PM the MARs were reviewed from (MONTH) (YEAR) through 11/15/18. The behavior monitoring section for [MEDICAL CONDITION] medication ([MEDICATION NAME]) documented that Resident #15 was not having any psychotic behaviors. On 11/15/18 at 12:22 PM, the Medical Director (MD) #115 was interviewed. He stated Resident #15's [MEDICATION NAME] was to be reduced in (MONTH) (YEAR). He stated that he tries to get all his residents off of [MEDICATION NAME] if they have a [DIAGNOSES REDACTED]. On 11/15/18 at 1:12 PM, Resident #15 was observed to be back in bed and sleeping. On 11/15/18 at 1:20 PM, the District Director, Clinical Resources (DDCR) #112 was interviewed. The DDCR was a Registered Nurse. The DDCR reviewed Resident #15's clinical record and stated that the physician's orders [REDACTED]. On 11/15/18 at 4:08 PM, the Physician's Assistant (PA) #114 was interviewed. His goal was to discontinue Resident #115 from [MEDICATION NAME]. PA #114 stated that he knows that [MEDICATION NAME] is not a recommended drug for elders with dementia.",2020-09-01
462,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-11-15,761,E,0,1,T4YY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observations and staff interviews, the facility failed to label open vials in two of two medication storage rooms and lock one of four medication carts. The facility census was 87. Findings include: On 11/12/18 at 8:00 PM, the medication cart identified as South 2 was noted to be unlocked with no staff observed in eyesight for 4 minutes. The treatment cart was also found unlocked in hallway near room [ROOM NUMBER]. The top drawer of the cart contained various creams and ointments. Residents were observed sitting in chairs in the hall and ambulating in the hall. At 8:04 PM, Registered Nurse (RN) #2 returned to the cart, then left it again, unlocked, for another 4 minutes. At 8:29 PM, the South 2 medication cart was left unlocked while RN #2 administered medications to a resident. The medication cart was not within eyesight of RN #2. An interview was completed with RN #2 on 11/12/18 at 8:35 PM. She stated, I didn't lock the cart because I wasn't gone very long and I was going to come right back and prepare more medications. If' I'm going to be gone for a long time, I will lock it because we have residents who walk in the hall and will steal. An interview was completed with the Director of Nurses (DON) on 11/12/18 at 9:08 AM. The DON said, If the nurse isn't with the cart they should lock the cart. If they are turning their back to the cart or walking away from the cart, it should be locked. On 11/14/18 at 3:36 PM, an observation of the South Station Medication room was completed. One bottle of [MEDICATION NAME] Purified Protein Derivative (TB PPD) was noted to be opened but not dated. A pill splitter was observed to have white powder covering the cutting area. On 11/14/18 at 3:38 PM, an interview was completed with Licensed Practical Nurse (LPN) #6. LPN #6 said that she could not tell when the vial was opened and that the nurse who opens a vial is supposed to write the date on the box and on the bottle. The pill splitter should be cleaned at the beginning of the shift and after each use. During observation of the North medication room on 11/14/18 at 3:46 PM, a second bottle of TB PPD was observed to be open and not dated. A pill crusher was observed to have a large amount of pale yellow powder in the bottom. Review of facility policies was completed on 11/13/18 at 3:15 PM. A policy dated 09/15, titled Safe Injection Practices noted, [NAME] If a multi-dose vial is used, it is to be labeled with a 28 day expiration date when opened and discarded on the 28th day. The policy titled Medication Cart Use dated 2008 noted Security-The medication cart and its storage bins are kept locked until the specified time of medication administration. During routine administration of medications, the cart may be kept in the doorway of the resident's room with: drawers unlocked and facing inward, and within sight of the nurse.",2020-09-01
463,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-11-15,770,D,0,1,T4YY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to ensure laboratory blood testing was obtained per physician order [REDACTED]. Findings include: A comprehensive chart review for Resident #48 was conducted on 11/13/18 at 2:00 PM. The Admission Record identified Resident #48 was originally admitted to the facility on [DATE]. The resident had a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #48's hospital Discharge Summary dated 10/05/18 revealed a physician's orders [REDACTED]. [MEDICATION NAME] is an antibiotic drug used to treat serious, life-threatening infections by gram-positive bacteria that are resistant to less-toxic agents. A Physician order [REDACTED]. A CBC is a laboratory blood test used to evaluate the resident's overall health and detect a wide range of disorders, including [MEDICAL CONDITION], infection and [MEDICAL CONDITION]. Additional laboratory work ordered included a comprehensive metabolic panel (CMP) used to check the status of the residents metabolism, including the health of the kidneys and liver as well as electrolyte and acid/base balance and levels of blood glucose and blood proteins; to monitor known conditions, such as hypertension, and to monitor the use of medications to check for any kidney or liver related side effects. Additionally, the physician ordered an erythrocyte sedimentation rate (ESR or sed rate) which is used to help detect inflammation associated with conditions such as infections, cancers, and [DIAGNOSES REDACTED] diseases, and a [MEDICATION NAME] trough level which is used to determine effective dosage for the antibiotic. The blood tests were to be drawn every 7 days. Review of the plan of care dated 11/03/18 included the Focus of, I receive antibiotic therapy r/t [MEDICAL CONDITION]. Included was an intervention to Obtain ordered labs as indicated. Further review of the clinical record revealed CBC test results dated 11/06/18; however, the clinical record did not contain the CMP, ESR or the [MEDICATION NAME] trough level as ordered by the physician. During an interview conducted on 11/12/18 at 1:00 PM, Unit Manager Registered Nurse (RN) #29 verified the CMP, ESR and [MEDICATION NAME] trough level blood testing was not collected as ordered by the physician. During an interview conducted on 11/15/18 at 12:05 PM, Medical Director #113 verified the facility did not follow his order to obtain the CMP, ESR and [MEDICATION NAME] trough level as written on 10/31/18.",2020-09-01
464,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-11-15,809,D,0,1,T4YY12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on random observation, resident interview, record review and staff interview the facility failed to ensure Resident # 81 was provided a meal at the regular scheduled time. This meal was not in accordance to Resident #81's needs and preferences. This was a random observation. Resident identifier: #81. Facility Census: 85. Findings included: a) Resident #81 During the initial tour on 01/29/19 at 9:30AM resident was observed sitting in her bed awaiting her breakfast tray. Resident was interviewed where she stated she had not received her breakfast tray and usually it came around 8:00 AM each morning. Resident had self-administered medication on her bedside table in which she stated she could not take without her food. Resident was observed pressing her call light where she informed Nursing Assistant (NA) # 42 she had not received her breakfast tray. NA #42 stated that she would get her a breakfast tray. In an interview, on 01/29/19 at 9:40AM, NA #42 stated Resident #81's breakfast tray just got missed. NA #42 explained that there were four (4) Nursing Assistants passing out breakfast trays that morning and they each thought the other one had delivered a tray to Resident #81. In an interview, on 01/29/19 at 2:40PM, Dietary Manager #89 stated that he was informed by staff that Resident #81 had not received a breakfast tray. Dietary Manager #89 confirmed that he personally made a breakfast tray up and had it delivered to Resident #81's room. Based on record review, on 01/30/19 at 9:00AM, Resident #81 had an active [DIAGNOSES REDACTED]. Based on Care Plan a goal for Type II Diabetes Mellitus is to continue to have no complications. Based on physician orders [REDACTED]. On 1/30/19 at 10:40AM, District Director of Clinical Services (DDCS) #90 provided a copy of a concern form revealing Resident #81's concern of not being provided a breakfast tray without having to ask for a tray. The concern form stated, Resident #81 did not receive a breakfast tray on 01/29/19 from the meal cart during breakfast. Dietary Manager #89 completed the concern form stating, once being notified by staff at 9:30AM Resident #81 did not have breakfast a tray was made and delivered to Resident #81. Documentation revealed that Dietary Manager #89 will monitor passing of breakfast trays for the next few weeks to ensure Resident #81 obtains a meal tray in the future. Unit Manager #71 and Dietary Manager #89 will audit trays to ensure Resident #81 receives daily and will review outcome with the Quality Assurance and Performance Improvement (QAPI) Team.",2020-09-01
465,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-11-15,838,J,0,1,T4YY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and Facility Assessment review, the facility identified providing services to residents receiving Intravenous (IV) therapy via a peripheral IV and peripherally inserted central catheter (PICC); however, failed to ensure staff were competent to provide the care needed for this resident population resulting in Immediate Jeopardy. This affected two (Resident #48 and #32) of two sampled residents receiving Intravenous (IV) therapy via a PICC. The facility census was 87. On 11/13/18 at 7:56 PM, the Administrator and Director of Nursing were notified verbally that Immediate Jeopardy began on 10/05/18 when Resident #48 was admitted to the facility with a PICC and receiving IV antibiotics. The Immediate Jeopardy continued 11/05/18 when the facility readmitted Resident #32. The Facility assessment dated [DATE] identified providing care and services to residents receiving IV therapy via peripheral IVs and PICC. LPN's #27, #33, #49 and #59 performed IV therapy for Resident #48 and LPNs #6, #20, #39, #49 and #64 performed IV therapy for Resident #32 without adequate training and skill competency in accordance with the Facility Assessment. Immediate Jeopardy was abated on 11/13/18 at 8:10 PM. The facility revised the staffing schedule to ensure a Registered Nurse (RN) would be performing IV therapy for the two residents any newly admitted residents with IV access. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a 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 as identified in the Facility Assessment. See F684 (Quality of Care), F867 (QAPI) and F726 (Staff Competency) for additional information. The facility census was 87. Findings include: The Facility Assessment tool dated 11/10/17 was reviewed on 11/15/18 at 10:10 AM. The facility assessment included a the section titled, Special Treatments and Resident Care Needs. At the time the facility assessment was completed, the facility had one resident with a peripheral IV, five residents with PICC lines and two residents receiving IV medications. Additionally, included in the facility assessment was a section titled, Additional References to the Facility Assessment. The facility assessment quoted the Code of Federal Regulations regarding Nursing Services and Training Requirements. The facility assessment stated: CFR 483.35 Nursing Services from the Code of Federal Regulations- The facility must have 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, as determined by the resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. CFR 483.95 Training Requirements- A facility must develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under contractual arrangement; and volunteers, consistent with their expected roles. A facility must determine the amount and types of training necessary based on the facility assessment as specified at 483.70(e) of the code of federal regulations. The section titled, Resident Support/Care Needs Medications was reviewed. The section stated administer medications by appropriate route including intravenous (peripheral or central lines). The section titled, Staff training/education and competencies was reviewed. The : Training Requirements for Licensed Nurses included a valid Nursing license (RN or LPN) and Annual CEUs, LPNs 24 hours each two-year reporting period. Compliance training, HIPPA General Privacy training, Sexual Harassment Education, Dementia training See Licensed Nurse Competency Checklist. The Licensed Nurse Competency Checklist used by the facility to assess competency with Intermittent administration of intravenous fluids was reviewed. The checklist did not include care of a resident with a PICC line. During an interview conducted on 11/14/18 at 1:15 PM, Director of Clinical Resources RN #112 verified the training material used by the facility during new employee orientation and the Licensed Nurse Competency Checklist did not specifically include care of a resident with a PICC line. In addition, she verified the training material for the IV Certification conducted on 07/05/17 did not include content for residents receiving intravenous medications through a PICC line. During an interview on 11/15/18 at 10:30 AM, Administrator #45 stated he was not employed by the facility at the time of the development of the Facility Assessment; and therefore, was not aware of the content of the Facility Assessment. During an interview conducted on 11/15/18 at 10:45 AM, Director of Nursing #46 stated she participated in the development of the Facility Assessment. She verified the Facility Assessment identified caring for residents receiving intravenous therapy through the Facility Assessment. She verified the facility assessment did identify the need for competency with PICC lines even though at the time of the assessment there were five residents with PICC lines.",2020-09-01
466,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-11-15,867,J,0,1,T4YY11,"Based on staff interview and policy review, the facility QAA committee failed to identify Licensed Practical Nurses (LPNs) were performing Intravenous (IV) therapy without sufficient training and implement an appropriate plan of action. This resulted in an Immediate Jeopardy. The facility census was 87. On 11/13/18 at 7:56 PM, the Administrator and Director of Nursing were notified verbally that Immediate Jeopardy began on 10/05/18, when Resident #48 was readmitted with a peripheral inserted central catheter (PICC). In (MONTH) (YEAR), the facility conducted a medication management audit through the Quality Assurance and Performance Improvement (QAPI) committee. However, the audit did not include medication management for residents receiving IV therapy or PICCs in order to determine training needs and competency skills. Immediate Jeopardy was abated on 11/13/18 at 8:10 PM. The facility completed an assessment of residents currently receiving IV therapy via PICC and revised staffing schedules. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a severity level two (no actual harm, with potential for more than minimal harm that is not Immediate Jeopardy) until the training and competency of LPNs are addressed in the QAA committee in accordance with the Quality Assurance and Performance Improvement (QAPI) plan. See F684 (Quality of Care), F726 (Staff Competency), and F838 (Facility Assessment) for additional information. Findings include: Facility documentation review was conducted on 11/15/18 at 12:00 PM and included the following. The Quality Assurance & Performance Improvement Program and Committee policy and procedure dated (MONTH) (YEAR) revealed, The facility maintains an ongoing, effective, comprehensive, data-driven Quality Assurance and Performance (QAPI) Program. The QAPI Program is managed by the QAPI Committee, which is responsible to the facility's Governing Body. The Quality Plan dated 11/01/17 under Addressing Care and Services stated, the QAPI program will strive for safety and quality with all clinical interventions and service delivery. The scope of the QAPI program covers all types and segments of care and services that impact clinical care, quality of life, resident's choice, and care transitions. During an interview conducted on 11/15/18 at 12:15 PM, Medical Director #113 stated he regularly attends the monthly quality assurance meetings. He stated that he was unaware LPNs were administering IV therapy without adequate training and competency assessments to ensure appropriate care and services were being delivered to residents with PICC lines. He stated the quality of the work being done by the QAPI committee had declined related to staff turnover. He stated his expectation was for nurses to be trained on the care they were providing. During an interview conducted on 11/15/18 at 12:50 PM, District Director of Clinical Services #112 stated on 10/15/18, she began a medication management audit through their QAPI program. The audit was conducted to identify concerns regarding medication management processes which included medication administration. However, the audit did not include any documentation of intravenous therapy or PICCs. During an interview conducted on 11/15/18 at 1:10 PM, Administrator #45 stated through their QAPI program they had not discovered that LPNs were performing IV therapy without training and competency assessments to ensure appropriate care and services were being delivered to resident's with PICC lines.",2020-09-01
467,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-11-15,947,E,0,1,T4YY11,"Based on record review and interviews, the facility failed to provide nurse aide training that included dementia training and abuse training. This affected 12 out of 35 Certified Nurse Aides (CNAs) that were employed for over 12 months. The facility census was 87. Findings include: On 11/14/18 at 9:38 AM, the Director of Staff Development (DSD) #5 was interviewed. DSD #5 stated that she had been employed for approximately three months and was trying to organize files from the previous DSD. DSD #5 stated that she was not aware of required annual training for CNAs that had to include abuse training and dementia training. On 11/14/18 at 1:35 PM, the Nursing Home Administrator (NHA) #45, the Director of Nursing (DON) #46 and the District Director, Clinical Resources (DDCR) # 112 were interviewed. The DON #46 stated that they have had turnover in the DSD position and could not find proof of required training. The DON stated that she knew Abuse training was provided but couldn't recall if that was in in (YEAR) or (YEAR). On 11/15/18 at 9:48 AM, the Regional Human Resources Consultant (HR) #116 was interviewed. HR #116 provided a list of all CNAs with their hire dates and the date of their last performance review. HR #116 stated that the facility usually completed the annual performance reviews during the months of (MONTH) and December. HR #116 stated that she was aware that CNAs were required to have 12 hours of training annually, but did not know that it had to include Abuse training and Dementia training On 11/15/18 at 2:19 PM, DSD #5 was interviewed. DSD #5 was unable to provide proof of 12 hours of education that included Abuse training and Dementia training On 11/15/18 at 3:00 PM, DDCR #112 was interviewed. DDCR #112 stated that they were not able to find evidence that all required training had been completed.",2020-09-01
468,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2019-12-05,550,D,0,1,QN1C11,"Based on a observation during random opportunity for discovery and staff interview, the facility failed to ensure the dignity of a resident during the dining experience. This affected one (1) resident who partook of her meal in the main dining room while housekeeping staff cleaned the room. Resident #41. Facility census 91. Findings include: a) Resident #41 On 12/02/19 at 1:50 PM Resident #41 sat in the main dining room as she ate her lunch meal. She was the only resident left in the room who was still eating. Three (3) housekeeping staff were engaged in sweeping the floor and cleaning up in the front section of the dining room. Another employee ran a motorized contraception in the dining room which cleaned the floor. No other facility staff were present in the dining room. An interview was conducted with the director of nursing and the administrator on 12/05/19 at 12:15 PM. They said cleaning the dining room while a resident was still eating was not a practice they condoned. They said typically lunch is served in the main dining room from approximately 12:20 PM to about 1:15 PM. They were not sure why she was still in the dining room eating so late. No further information was provided prior to exit.",2020-09-01
469,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2019-12-05,561,D,0,1,QN1C11,"Based on record review, resident and staff interview the facility failed to provide for personal preference related to resident bathing preferences. This affected one (1) of one (1) resident for choices. Resident #59. Facility census 91. Findings included: Resident #59 During an interview with Resident #59 (R#59), on 12/03/19 at 3:30 PM, Resident #59 stated she was showered around midnight. R#59 prefers morning showers, in particular 6:00 AM showers. Further, R#59 does not wish to be awakened to shower. A record review found the current care plan for R#59, with R#59's preferred bedtime listed as between 8:00 PM and 9:00 PM On 12/04/19 at 9:20 AM, during an interview with Nursing Home Administrator (NHA) it was discovered that the facility completed a shower preference audit in June, 2019. R#59 chose morning showers, with 6:00 AM listed on the audit sheet. NHA confirmed this is R#59's choice. During an interview with Registered Nurse/Staff Development Coordinator #37, on 12/04/19 at 10:25 AM, it was confirmed R#59 was showered at: 5:34 AM on 11/29/19, 6:59 AM on 11/26/19, 12:45 AM on 11/22/19, 3:56 AM on 11/19/19, 6:54 AM on 11/15/19 12:01 AM on 11/12/19, 5:11 Am on 11/05/19, 6:59 AM on 11/01/19. RN #37 confirmed these times are not the chosen shower times for R#59.",2020-09-01
470,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2019-12-05,578,D,0,1,QN1C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure complete medical records. Specifically, the West Virginia Physician order [REDACTED]. This affected three (3) of three (3) residents reviewed for advance directives. Resident Identifiers: #56, #284, and #285. Facility census 91. Findings included: Record review on 12/03/19, revealed three West Virginia Physician order [REDACTED]. a) POST form for Resident #56, dated 10/25/19, found: 1. no social security number 2. no printed name of MD/DO/APRN/PA or phone number of representative approving orders 3. no name on the second page 4. section [NAME] (preferences as a guide for POST form) was not completed, other than the person preparing form section b) POST form for Resident #284, dated 11/08/19, found: 1. no address 2. no social security number 3. no printed name of MD/DO/APRN/PA or phone number of representative approving orders 4. no information completed in Section E, (preferences as a guide for POST form) other than the person preparing the form section c) POST form for Resident #285, dated 10/21/19, found: 1. no address 2. no social security number 3. no birthdate 4. no information in Section C, (medically administered fluids and nutrition) on the first page 5. no printed name of MD/DO/APRN/PA or phone number of representative approving orders 6. no information completed in Section E, (preferences as a guide for POST form), other than the person preparing the form section An interview with Registered Nurse #58 on 12/04/19 at 1:47 PM, RN #58 revealed the form should be complete in all areas. RN #58 reported that POST forms for R #56, R #284 and R #285 were not complete.",2020-09-01
471,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2019-12-05,655,D,0,1,QN1C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review the facility failed to develop and implement a base line care that included instructions needed to provide effective person centered care of the resident which met professional standards of quality care. This was evident for one (1) of one (1) residents reviewed for [MEDICAL CONDITION] care. Resident identifier: #187. Facility census 91. Findings include: a) Resident #187 The medical record was reviewed on 12/03/19. This resident first came to the facility on [DATE]. He received a [MEDICAL CONDITION] during a hospitalization which immediately preceded his admission to the facility. The care plan as related to [MEDICAL CONDITION] was sparse. It directed to [MEDICAL CONDITION] were secured at all times, humidified oxygen (did not include percentage or equipment settings), suction as necessary, keep an [MEDICAL CONDITION] and obturator at bedside - if coughed out, open stoma with a hemostat if tube cannot be reinserted. The care plan did not include the type and size of the airway. Observation of the resident on 12/03/19 at 3:45 PM found him lying in bed with the head of the bed elevated. He received humidification to [MEDICAL CONDITION] from a Heavy Duty Aerosol Compressor. This machine sat upon a bedside table to the left of the resident's bed. A portable suction machine also sat upon the bedside table. There was no suction catheter or yonker at the machine. On the right of the resident's bed an oxygen concentrator sat on the floor. This machine was turned on and was delivering oxygen at six (6) liters per minute (lpm). The opposite end of the oxygen tubing lay in his bed but was not connected to anything. An interview was conducted with licensed nurse #119 (LPN #119) on 12/03/19 at 3:45 PM. She acknowledged the concentrator was set for, and running, at six (6) lpm, but the tubing was laying on the bed and not connected to anything. She said he was not receiving oxygen, rather just humidified air. She said the Heavy Duty Aerosol Compressor was set on 40 on the dial. She said it delivered 28% humidification and showed on another dial as such. She said she would have to check orders to see about the settings as this was the way in which it was set. When told her there was nothing in the physician's orders or the care plan about the settings, she said she would look for the unit manager. She showed that the suction catheters were inside the resident's closet which was located against the wall across from the foot of the resident's bed. At 3:55 PM on 12/03/19 LPN #119 was observed in the front hall talking with unit manager registered nurse #58 (RN #58). The following issues were discussed with RN #58: 1. The suction machine at the bedside had no suction catheter at the bedside for emergency suctioning. 2. The dial on the Heavy Duty Aerosol Compressor was set on 40, and it appears that the setting on the humidifier bottle may be at 28%. However, there are no MD orders or care planned directives as to how to set this machine or the humidifier bottle. 3. The humidifier bottle on the Heavy Duty Aerosol Compressor had an expiration date of (MONTH) (YEAR). RN #58 then walked to the resident's room. While en route, she asked health information coordinator #101 (HIC #101) if they had Tupperware containers and if Resident #187 had one at his bedside. HIC #101 replied they do have Tupperware containers, but that Resident #187 had none yet at his beside. RN #58 agreed the humidifier bottle was beyond the expiration date, and she obtained a fresh one. She looked at the oxygen concentrator. Someone had come in and removed the oxygen tubing from the concentrator and turned it off. She agreed there was no suction catheter at the bedside for emergency if needed. She looked inside the resident's closet which had a jumble of oxygen therapy equipment inside, and found a sterile suction catheter/bag and laid it by the suction machine. She said had the Tupperware box been at the bedside that the suction catheter would have been inside it. She said she understood that it should be at the bedside as in an emergency people want it quickly. She looked at the dial on the Heavy Duty Aerosol Compressor. She said it was set by the respiratory therapist. She was informed that there were no parameters to follow in the physician's orders or the care plan regarding the settings. She said the physician is here today and she will ask him about clarification in the orders. She said she will also update the baseline care plan. Further review of the medical record on 12/04/19 found the following entries for pulse oximetry: -11/28/19 - 97% at 6:28 PM, 94% at 6:55 PM and 94% at 4:19 PM -11/29/19 - 94% at 3:15 PM, and 95% at 7:38 PM -11/30/19 - 94% at 1:18 PM -12/01/19 - 94% at 3:05 PM -12/02/19 - NONE RECORDED -12/03/19 - 98% at 7:27 PM On 12/04/19 at 9 AM an interview was conducted with the director of nursing (DON). It was discussed that pulse oximetry readings were only done and/or recorded sporadically since admission as noted on the dates and times above. She agreed there were no physician's orders or care planned directives as to how often to assess his oxygen level. When asked how often she expected staff to obtain pulse oximetry rates, she said only when the physician orders it. An interview was conducted on 12/04/19 at 9:15 AM with RN #58. She said his pulse oximetry measurement has always been above 92% so they do not routinely check it as he is on room air, not oxygen. When asked what their policy directed for the frequency of pulse oximetry measurement for residents with trachs, she said that staff should check the resident's pulse oximetry whenever they [MEDICAL CONDITION], and before and after suctioning, but they do not always write it down. RN #58 said staff should document each time they assess the pulse oximetry. She acknowledged the standard that it if it is not documented, then it did not happen. An interview was conducted with staff development registered nurse #36 on 12/04/19 at 9:30 AM. When asked what [MEDICAL CONDITION] policy and procedure said about assessing pulse oximetry, she said it just says to assess the patient. She said she obtains pulse oximetry assessment at least before and after care provided to the trach. She said she could not speak for all nurses that they are documenting pulse oximetry results. At 10:30 AM on 12/04/19 RN #58 brought a copy of a policy titled [MEDICAL CONDITION] Management which had a release date of (MONTH) (YEAR) as a Clinical Practice Standard; a copy of a policy titled Spontaneous Decannulation: Reinsertion of [MEDICAL CONDITION] with revision date (MONTH) 2008; and another titled Tracheal Button Insertion, with revision date (MONTH) 2008. None of these address obtaining oxygen levels per pulse oximetry. An interview was conducted with the administrator and the DON on 12/05/19 at 12:15 PM. It was discussed that the baseline care plan was found silent as to the settings of the Heavy Duty Aerosol Compressor and the percentage of humidification; how often to assess and document pulse oximetry measurements; the type and size of the airway, and the provision of all emergency equipment at the bedside which includes suction catheters. They acknowledged understanding. No further information was provided prior to exit.",2020-09-01
472,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2019-12-05,657,D,0,1,QN1C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, the facility failed to revise a care plan related to support required for a resident's toileting needs. This affected one (1) of one (1) residents reviewed for the care area of bowel and bladder incontinence. Resident #60. Facility census 91. Findings included: a) Resident #60 A review of Resident #60's quarterly Minimum Data Set (MDS) with the Assessment Reference date (ARD) of 09/17/19 and 11/04/19 finds Resident #60 requires extensive assistance and one (1) person physical support for his toileting needs. Resident #60's Brief Interview for Mental status (BIMS) finds Resident #60 scored a 13 on his BIMS for 11/04/19. A score of 13-15 indicate an intact cognitive response. The MDS's reveals the resident can make himself understood and understands others. A review of the look back period on Resident #60's toileting support for the MDS dated [DATE], revealed the staff provided one (1) person assistance for his toileting support. A review for the look back period for the resident's toileting support for the MDS dated , 11/04/19 finds one (1) person physical assist. In an interview with Resident #60 on 12/02/19 3:38 PM, he was asked what support do you need to use the toilet. The resident stated one (1). An interview was conducted on 12/03/19 at 3:00 PM, with Resident Care Specialist (RCS) #79. When he was asked what support assistance does Resident #60 require to go to the toilet the RCS stated that, Resident #60 required the support of one (1) assistant to use the toilet. A review of Resident #60's care plan on 12/03/19 at 2:10 PM, found a care plan saying: I have an activity of daily living (ADL) self-care performance deficit related to impaired mobility. This care plan focus was initiated on 04/03/19 and a revision was made on 09/25/19. Resident #60's intervention for his toilet use is: the resident requires extensive assistance by two (2) staff for toileting. The date for this intervention is 04/03/19. Resident #60's Kardex ( ) revealed Resident #60's requires the extensive assistance of two (2) staff for his toileting needs. In an interview on 12/03/19 at 3:25 PM, the Care Management Minimum Data Set Director (CMMDSD) Registered Nurse (RN) #33, she was informed of Resident #60 required one (1) assist for his toileting support on the MDS dated [DATE] and 11/04/19. RCA #79 stated that Resident #60 needed one (1) assistance for toileting support. The care plan and the Kardex said two (2) assistance is requires for the resident's toileting support. The CMMDSD said the Kardex/care plan needed to be updated to reflect Resident #60's support required for his toileting needs.",2020-09-01
473,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2019-12-05,684,D,0,1,QN1C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice. A stat Basic Metabolic panel (BMP)lab was ordered and the staff failed to inform the physician and/or Physician Assistant (PA) timely of the stat BMP lab results. The resident was hosptalized on [DATE] and had a stent placed. This had the potential to affect one (1) of one (1) resident reviewed for stat lab work. Resident Identifier #60. Facility census 91. Findings included: a) Resident #60 A review of Resident #60 medical [DIAGNOSES REDACTED]. diabetic [MEDICAL CONDITION] - 03/13/19 [MEDICAL CONDITION] - 03/13/19, [MEDICAL CONDITION] - 03/13/19, malignant neoplasm of prostrate - 03/13/19, end stage [MEDICAL CONDITION] - 03/13/19, [MEDICAL CONDITION] - 03/13/19, mild cognitive impairment - 03/18/19, muscle weakness - 03/26/19 , difficulty in walking - 03/26/19 , non-St elevation (NSTEMI) [MEDICAL CONDITION] infraction - 05/07/19 present of coronary angioplasty implant graft - 05/07/19. On 04/30/19 at 6:50 AM, Resident #60 refused his shower on night shift. Registered Nurse (RN) #779 stated the resident said, I feel tired and probably take it the next day. A review of the Resident #60's medical records find a progress note on 05/01/19 revealing Resident #60 was being transported by emergency medical system to receive his [MEDICAL TREATMENT]. The resident had his vital signs checked in the truck, prior to leaving out to the [MEDICAL TREATMENT] center. Resident #60's blood pressure was noted to be 90/60. The note stated this blood pressure is average on multiple attempts. The [MEDICAL TREATMENT] center was informed of the resident's blood pressure and the [MEDICAL TREATMENT] center stated the resident could not come to [MEDICAL TREATMENT]. The [MEDICAL TREATMENT] center made the recommendation to have Resident #60's potassium level checked. The PA was notified and order were given to obtain a stat BMP. The resident [MEDICAL TREATMENT] was rescheduled for 05/02/19 at 6:00 AM. A progress note dated 05/01/19 at 8:38PM, LPN #84 wrote that she did not perform Resident #60's dressing. The LPN wrote, Drsg. (sic) today due to him not feeling well. VSS (sic). Skin color pale. Just kept saying lets do it later and time ran out. Sleeping most of the day. No lab results of yet. A review of progress notes finds no note notifying the physician or PA of the stat BMP lab results. There were four (4) copies of the BMP stat lab results from (Medical Center name) in Resident #60's record. The date and the time the facility's system generated the results of the stat BMP lab results on 05/01/19 was at 11:38 AM for three(3) of the lab results and one (1)of the the lab results had the time of 12:27 PM on 05/01/19. Resident #60's physician signed the stat lab results for the BMP on 05/07/19. Resident #60's stat BMP lab results for 05/01/19 were in the resident's chart. The lab results revealed Resident #60's lab results were Glucose -138 High (H) milligrams per deciliter (MG/DL)reference range is 74-100. ( glucose -measure the amount of glucose in your blood).Blood Urine Nitrogen ( Bun)was 47 MG/DL- H, reference range is 7-18, the BUN- measures how much of the waste product you have in your blood). The resident's sodium 134 -L, millimoles per liter (mmol/l -low ), (sodium level checks how much sodium is in the blood), reference range is 136-145, Potassium - 2.9 MMOL/ L-L(Potassium is the amount of potassium in the blood),Reference range is 3.5-5.1, Chloride- 93 MMOL/ L- L , Preference range is 98-107, Creatinine 4.39 MG/DL H, reference range is 0.70-1.30, EGFR in non-African American -13 ML/Min/1.73 m2 = square meters, reference range >=60. On 05/04/19 at 11:48 AM, Licensed Practical Nurse #84, revealed that Resident #60 has shortness of breath (SOB), complaining of abdominal pain, diarrhea times three (3). The resident's Hemoglobin level is 7.2. Hemoglobin is a protein in red blood cells that carries oxygen. The hemoglobin test measures how much hemoglobin is in your blood. The resident's oxygen was 86% on room air. The nurse applied oxygen applied via nasal cannula at two (2) liters per minute. The resident oxygen saturation increased to 94%. The resident's skin color is is pale and he is nauseated. LPN #84 writes Due to his ADB. (abdominal)pain and diarrhea resident is not eating. IDDM. (Insulin Dependent Diabetic Mellitus). The family/health care agent was notified on 05/04/19 at 11:00 AM and the PA was notified at 1:00 PM. A progress note written by LPN #84 on 05/04/19 6:34 PM, revealed Resident was admitted to (hospital name) The resident had an stent placed. Fremont Rideout Health Group Laboratory Services defines Stat test as a test result that are urgently needed for the [DIAGNOSES REDACTED]. The lab performs the test in one (1) hour of less from when the sample was received in the laboratory. The results are available for review. BUN, Chloride, Creatinine, Glucose, Potassium, and Sodium are tests that can be ordered stat. Medline plus.gov dated 02/28/18 reveals that hemoglobin is a protein in red blood cells that carries oxygen. The hemoglobin test measures how much hemoglobin is in your blood. Normal hemoglobin levels generally range from 13.8 to 17.2 grams per deciliter in males. Hemoglobin is an oxygen-carrying protein found in red blood cells. Medlineplus.gov reveals on 04/08/19 that nausea is a symptom of low Potassium. Medline plus.gov dated 10/01/19, finds the body needs Potassium to help your heart and muscles work properly. Potassium levels that are too high or too low may indicate a medical problem. Too little potassium in the blood, a condition known as [DIAGNOSES REDACTED], may indicate loss of bodily fluids from diarrhea. A nursing progress note on 05/06/19 at 6:52 written by LPN # 84 revealed Resident #60 was readmitted from (hospital's name )at approximately 4:30 PM. The LPN stated that, And a stint (sic) was placed in RC[NAME] A physician note dated 05/07/19 7:15 PM, revealed Resident #60 was readmitted . The resident went to (hospital name), and found to have a [MEDICAL CONDITION] infract ([MEDICAL CONDITION]), the patient has a stent. Health line.com says that acute [MEDICAL CONDITION] infarction is the medical name for a [MEDICAL CONDITION]. A [MEDICAL CONDITION] is a life-threatening condition that occurs when blood flow to the heart muscle is abruptly cut off, causing tissue damage. This is usually the result of a blockage in one or more of the coronary arteries. A blockage can develop due to a buildup of plaque, a substance mostly made of fat, cholesterol, and cellular waste products. While the classic symptoms of a [MEDICAL CONDITION] are chest pain and shortness of breath, the symptoms can be quite varied. The most common symptoms of a [MEDICAL CONDITION] include: nausea and short of breath. Mayo clinic reveals 11/15/19 that Coronary angioplasty, also called percutaneous coronary intervention, is a procedure used to open clogged heart arteries. Angioplasty uses a tiny balloon catheter that is inserted in a blocked blood vessel to help widen it and improve blood flow to your heart. A placement of a small wire mesh tube called a stent. The stent helps prop the artery open, decreasing its chance of narrowing again. Most stent's are coated with medication to help keep your artery open (drug-eluting stent's). Rarely, bare-metal stents may be used. A nurse progress note revealed on 05/09/19 at 2:14 PM by LPN #84 revealed Resident #60 left leave of absent (LOA) to a (heart institute name)and returned with a heart monitor on. The heart monitor is to stay on for 48 hours and after the 48 hours it is to stay on until some one from the heart institute comes and take the heart monitor off. On 05/12/19 at 8:25 PM, LPN #777, wrote a nursing progress note revealing Resident #60 was wearing a heart monitor for 48 hrs. Sunday evening he asked when they were coming to get it. Called the number that came with it and they knew nothing about it. After they called their boss they said she would be in today to pick it up. Took it off resident Sunday evening but they still haven't come for it. No further note about whether someone from the heart institute retrieve the heart monitor. No progress note of the results of the heart monitor. The staff provided no evidence upon exiting the building of the 48 hour heart monitor results. A Progress note written by LPN #778 on 05/14/19 at 10:52 AM, revealed Resident #60's stated, Resident's blood pressure running low. [MEDICATION NAME] HCl ('[MEDICATION NAME] Acid)10 milligrams( MG) was held. The record revealed Resident #60 is to be given one (1) 1 tablet by mouth every eight (8) hours related to Cardiac Arrhythmia. The resident's blood pressure on 05/14/19 at 10:58 PM was 94/58. LPN #778 stated that I evaluated the resident and checked BP manually and got 108/64. Over the past two ( 2) hours it has fluctuated 20 points both directions, but continues to be low. Resident states he feels fine and is asymptomatic. Pulse continues to stay between 65-80. The LPN wrote that he called the PA who ordered me to discontinue the [MEDICATION NAME] and [MEDICATION NAME] all together and to have the resident lay and rest until he can evaluate him in person. Will continue to monitor. In an interview on 12/04/19 at 12:00 PM, with Unit Manager #58 confirmed the staff should have notify the Physician/PA of Resident #60's stat BMP lab work on 05/01/19. In an interview with Registered Nurse #36 on 12/04/19 at 12:25 PM, was informed of Resident #60's above status and the staff did not notify the physician of the stat BMP. The resident was hosptalized on [DATE]. The physician signed off that he had reviewed the BMP stat labs of Resident #60 on 05/07/19. RN #36 was asked why the physician was not aware of Resident #60's labs until the day after the resident was re-admitted to the facility on [DATE] and the RN was asked did the lab work have a affects on why Resident #60 had to go to the hospital on [DATE]. The RN made no comment. The RN did make the comment that the nursing staff should have called the Physician and/or the PA of Resident #60's stat BMP lab results on 05/01/19. The RN acknowledges the date the physician signed the lab results is the date the physician was first aware of the results of the stat BMP. No comment made regarding the 48 hour heart monitor results. The PA on 12/04/19 1:53 PM reviewed Resident #60's four (4)lab results with the date of 05/01/19 with the Physician Assistant (PA). The PA confirmed the staff did not notify the physician nor him of the abnormal lab results. Resident #60's potassium level was 2.9 Low. The PA verified the physician reviewed and signed the results of the stat BMP on 05/07/19. No further comment was made related to Resident #60 being admitted for the [DIAGNOSES REDACTED].",2020-09-01
474,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2019-12-05,685,D,0,1,QN1C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, and staff interview, the facility failed to ensure a resident received proper assistive device (eye glasses) to maintain vision abilities. Resident identifier: #9. Facility census 91. Findings include: a) Resident #9 An interview was conducted with the resident on 12/02/19 at 1:38 PM. She said her eye glasses came up missing when she was in the hospital about a month or so ago. She said she most recently saw an eye doctor about a year ago, and she was not sure if they can do anything more to help her see better. The medical record was reviewed on 12/04/19. Review of the care plan with revision date 06/06/19 found she was care planned for vision deficits and that she wears glasses to watch TV. The care plan identified that her vision has recently worsened and her optometrist told her this was due to diabetes and [MEDICATION NAME] degeneration. The most recent comprehensive assessment, with assessment reference date 09/10/19, assessed that she was able to see in adequate light. It also assessed that she wore glasses. Review of the electronic health record found nursing assistants documented every day in the most recent 30-day look back period under tasks that she wore no glasses. An interview was conducted with unit manager registered nurse #58 (RN #58) on 12/04/19 at 3:20 PM. She provided evidence that this resident had an appointment in the facility with their contracted eye care provider 360 on 08/13/18. She said the resident had another appointment scheduled with 360 on 02/13/19, but missed the appointment because she was in the hospital. She said she assumes that the appointment with 360 on 02/13/19 was a follow-up only. Upon inquiry as to whether the appointment was rescheduled, she replied in the negative. She said this was the first she has heard of her missing glasses. She spoke her opinion that the glasses she wore were not prescription lenses, but instead were readers. She said the resident did not tell any staff that her readers were gone and she wanted them back. A second interview was completed with the resident on 12/05/19 at 11:05 AM. She said she would love to read large print books if she had her glasses. She said she may or may not watch TV as TV sometimes gets on her nerves. She said her missing glasses were prescription lenses, not readers. She said the lenses got darker in bright light. When asked who she told about the missing glasses, she said everybody. She said someone came by today and told her she has an appointment with the eye doctor here at the facility on 12/10/19. An interview was completed with nursing assistant #82 (NA #82) on 12/05/19 at 11:10 AM. She said she and other nurse aides were aware of the loss of the resident's glasses. She said she has looked for the resident's glasses to no avail. An interview was conducted with RN #58 on 12/05/19 at 11:15 AM. She verified that the vision company 360 will be at the facility next week to check her eyes. An interview was conducted with the director of nursing (DON) and the administrator on 12/05/19 at 12:15 PM. The DON spoke awareness that the resident is now scheduled for an eye exam at the facility next week, and said they will ensure she gets new glasses. No further information was provided prior to exit.",2020-09-01
475,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2019-12-05,695,D,0,1,QN1C11,"**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 a resident who needs [MEDICAL CONDITION] care and suctioning is provided care that is consistent with professional standard of practice. This affected one (1) of one resident reviewed for [MEDICAL CONDITION] care. Resident identifier: Resident #187. Facility census 91. Findings include: a) Resident #187 The medical record was reviewed on 12/03/19. This resident first came to the facility on [DATE]. He received a [MEDICAL CONDITION] during a hospitalization which immediately preceded his admission to the facility. Physician's orders did not address the humidification bottle's percentage setting, or the percentage pressure setting of the aerosol compressor. Physician's orders did not set parameters for the pulse oximetry measurements for when he should be notified or how often to obtain pulse oximetry measurements. The care plan as related to the [MEDICAL CONDITION] was sparse. It directed to [MEDICAL CONDITION] were secured at all times, humidified oxygen (did not include percentage or equipment settings), suction as necessary, keep an [MEDICAL CONDITION] and obturator at bedside - if coughed out, open stoma with a hemostat if tube cannot be reinserted. The care plan did not include the type and size of the airway. Observation of the resident on 12/03/19 at 3:45 PM found him lying in bed with the head of the bed elevated. He received humidification to [MEDICAL CONDITION] from a Heavy Duty Aerosol Compressor. This machine sat upon a bedside table to the left of the resident's bed. A portable suction machine also sat upon the bedside table. There was no suction catheter or yonker at the machine. On the right of the resident's bed an oxygen concentrator sat on the floor. This machine was turned on and was delivering oxygen at six (6) liters per minute (lpm). The opposite end of the oxygen tubing lay in his bed but was not connected to anything. An interview was conducted with licensed nurse #119 (LPN #119) on 12/03/19 at 3:45 PM. She acknowledged the concentrator was set at six (6) lpm running, but the tubing was laying on the bed and not connected to anything. She said he was not receiving oxygen, rather just humidified air. She said the Heavy Duty Aerosol Compressor was set on 40 on the dial. She said it delivered 28% humidification and showed on another dial as such. She said she would have to check orders to see about the settings as this was the way in which it was set. When told there was nothing in the physician's orders or the care plan about the settings, she said she would look for the unit manager. She showed that the suction catheters were inside the resident's closet which was located against the wall across from the foot of the resident's bed. At 3:55 PM on 12/03/19 LPN #119 was observed in the front hall talking with unit manager registered nurse #58 (RN #58). The following issues were discussed with RN #58: 1. The suction machine at the bedside had no suction catheter at the bedside for emergency suctioning. 2. The dial on the Heavy Duty Aerosol Compressor was set on 40, and it appears that the setting on the humidifier bottle may be at 28%. However, there are no MD orders or care planned directives as to how to set this machine or the humidifier bottle. 3. The humidifier bottle on the Heavy Duty Aerosol Compressor had an expiration date of (MONTH) (YEAR). RN #58 then walked to the resident's room. While en route, she asked health information coordinator #101 (HIC #101) if they had Tupperware containers and if Resident #187 had one at his bedside. HIC #101 replied they do have Tupperware containers, but that Resident #187 had none yet at his beside. RN #58 agreed the humidifier bottle was beyond the expiration date, and she obtained a fresh one. She looked at the oxygen concentrator. Someone had come in and removed the oxygen tubing from the concentrator and turned it off. She agreed there was no suction catheter at the bedside for emergency if needed. She looked inside the resident's closet which had a jumble of oxygen therapy equipment inside, and found a sterile suction catheter/bag and laid it by the suction machine. She said had the Tupperware box been at the bedside that the suction catheter would have been inside it. She said she understood that it should be at the bedside as in an emergency people want it quickly. She looked at the dial on the Heavy Duty Aerosol Compressor. She said it was set by the respiratory therapist. She was informed that there were no parameters to follow in the physician's orders or the care plan regarding the settings. She said the physician is here today and she will ask him about clarification in the orders. She said she will also update the baseline care plan. Further review of the medical record on 12/04/19 found the following entries for pulse oximetry: -11/28/19 - 97% at 6:28 PM, 94% at 6:55 PM and 94% at 4:19 PM -11/29/19 - 94% at 3:15 PM, and 95% at 7:38 PM -11/30/19 - 94% at 1:18 PM -12/01/19 - 94% at 3:05 PM -12/02/19 - NONE RECORDED -12/03/19 - 98% at 7:27 PM On 12/04/19 at 9 AM an interview was conducted with the director of nursing (DON). It was discussed that pulse oximetry readings were only done and/or recorded sporadically since admission as noted on the dates and times above. She agreed there were no physician's orders or care planned directives as to how often to assess his oxygen level. When asked how often she expected staff to obtain pulse oximetry rates, she said only when the physician orders it. An interview was conducted on 12/04/19 at 9:15 AM with RN #58. She said his pulse oximetry measurement has always been above 92% so they do not routinely check it as he is on room air, not oxygen. When asked what their policy directed for the frequency of pulse oximetry measurement for residents with trachs, she said that staff check the resident's pulse oximetry whenever they [MEDICAL CONDITION], and before and after suctioning, but they do not write it down. RN #58 said staff should document each time they assess the pulse oximetry. She acknowledged the standard that it if it is not documented, then it did not happen. An interview was conducted with staff development registered nurse #36 on 12/04/19 at 9:30 AM. When asked what [MEDICAL CONDITION] policy and procedure said about assessing pulse oximetry, she said it just says to assess the patient. She said she obtains pulse oximetry assessment at least before and after care provided to the trach. She said she could not speak for all nurses that they are documenting pulse oximetry results. At 10:30 AM on 12/04/19 RN #58 brought a copy of a policy titled [MEDICAL CONDITION] Management which had a release date of (MONTH) (YEAR) as a Clinical Practice Standard; a copy of a policy titled Spontaneous Decannulation: Reinsertion of [MEDICAL CONDITION] with revision date (MONTH) 2008; and another titled Tracheal Button Insertion, with revision date (MONTH) 2008. None of these address obtaining oxygen levels per pulse oximetry. An interview was conducted with the administrator and the DON on 12/05/19 at 12:15 PM. It was discussed that the baseline care plan was found silent as to the settings of the Heavy Duty Aerosol Compressor and the percentage of humidification; how often to assess and document pulse oximetry measurements; the type and size of the airway; and the provision of all emergency equipment at the bedside which includes suction catheters. It was discussed that physician's orders did not address the settings of the Heavy Duty Aerosol Compressor and the percentage of humidification; physician's orders did not set parameters for the pulse oximetry measurements for when he should be notified or how often to obtain pulse oximetry measurements. It was also discussed that the humidifier bottle in use on 12/03/19 had an expiration date of (MONTH) (YEAR). They acknowledged understanding. No further information was provided prior to exit.",2020-09-01
476,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2019-12-05,758,D,0,1,QN1C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the pharmacy first recognized a resident received a psychoactive medication, and then communicated to the physician of the need to consider a gradual dose reductions of the medication. This affected one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #9. Facility census 91. Findings include: a) Resident #9 Review of the medical record on 12/04/19 found this resident was initially prescribed an antidepressant medication on 07/11/18. The resident has continued on this medication and has remained on the same dose through the current date. Further review of the medical record found no evidence that the pharmacy had even once recommended to the physician the consideration of a gradual dose reduction (GDR). An interview was conducted with Health Information Coordinator #101 (HIC #101) on 12/05/19 at 9:30 AM. She said she reviewed all the pharmacy information for this resident and found nothing related to any pharmacy recommendations to the physician to consider a GDR of this antidepressant. An interview was conducted with registered nurse unit manager #58 (RN #58) on 12/05/19 at 10 AM. She said this resident is a hospice patient who entered hospice in (MONTH) 2019. It was discussed that the pharmacy did not relay to the physician a need for the consideration of GDR for [MEDICAL CONDITION] medications in two (2) quarters separated by at least one (1) month in the first year of administration ever since the start date of the medication on 07/11/19. She was unable to provide evidence that this resident had received a trial GDR of the antidepressant or of pharmacy recommendation to the physician to consider a GDR. Relayed that the physician has the right to decline a GDR if he/she includes a written rationale related to the declination. An interview was conducted with the director of nursing and the administrator on 12/05/19 at 12:15 PM. The lack of pharmacy communication to the physician related to consideration of a GDR for a [MEDICAL CONDITION] medication was discussed. No further information was provided prior to exit.",2020-09-01
477,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2019-12-05,842,D,0,1,QN1C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to maintain medical record on each resident that are complete and accurately documented. Residents inventory of personal effects form were not found in the residents medical record. This had the potential to affect two (2) of twenty -one resident reviewed during the annual survey. Resident #70 and #8. Facility census 91. Findings included: a) Resident #70 Resident #70 was admitted on [DATE]. Resident #70's quarterly Minimum Data Set (MDS) with the assessment reference date (ARD) of 11/24/19, reveals Resident #70 makes self understood, and understands others. Resident Brief Interview for Mental Status (BIMS) reveals Resident #70'S scored a 15 on her BIMS. In an interview on 12/02/19 at 11:54 AM, revealed Resident stated that, she had lost one (1) black skirt two (2) weeks ago. Resident #70 said the laundry told her they would look for the skirt. An interview was conducted with Laundry employee #17 on 12/04/19 at 8:55 AM. Laundry employee #17 stated that she was told about the skirt. She pointed to a note on the wall in the laundry room, which revealed Resident #70 had lost a black skirt. The laundry worker said she is looking for the skirt and if she does not find the skirt, she will do a concern form. The Administrator on 12/04/19 at 9:00AM, when asked where is residents inventory of personal effects forms in found in the resident hard chart. The Administrator stated that, the form should be found under miscellaneous section. A review of Resident #70's inventory of personal effects form in medical record on 12/04/19 at 9:20 AM, found no inventory of personal effects forms. b) Resident #8 Resident #8 was admitted on [DATE]. A review of Resident #8's quarterly MDS with the ARD of 11/24/19, reveals Resident #8 is identified that he can make self understood and understands others. In an interview with Resident #8 on 12/02/19 at 11:41 AM, the resident said he lost 25 diamonds in a gold ring. Resident #8 revealed that he reported this to the administrator a month ago. The Resident said the Administrator told him that he told him he would replace it. In an interview with Laundry employee #17 on 12/04/19 at 8:58 AM, she was asked whether she was asked to look for Resident #8's, 25 diamonds in a gold ring. Laundry employee #17 stated that, I was not aware (Resident's name ) had lost his ring nor was I told to look for the ring. A review of Resident #8's chart on 12/04/19 at 9:22 AM, found no inventory of personal effects form for Resident #8. In an interview and observation with Resident Care Specialist (RCS) #114 on 12/04/19 at 9:25 AM, she looked for Resident #70 and #8's inventory of personal effects forms. The RCS was unable to find a inventory of personal effects form in the residents record. The RCS stated that each resident should have a inventory of personal effects form completed when they are admitted to the facility. This form is found under the miscellaneous section. The RCS #114 asked the Unit Manager (UN) #58 on 12/04/19 at 9:30 AM, where Resident #8 and #70's inventory of personal effects forms could be found. The UN said under the miscellaneous section. The UM confirmed Resident #70's and #8's medical record did not contain their inventory of personal effects form when they had admitted the residents. The facility's policy revealed any persons clothing or possessions retained by the facility for the resident during his or her stay will be identified and inventoried upon admission using the inventory of personal effects form. A copy of the completed form is provided to the resident, another is placed in the resident's medical record and a third copy is included with any valuables placed in the facility safe or a locked cabinet. When the Administrator on 12/04/19 at 11:00 AM, was informed that Resident #8 stated that he had informed him (the Administrator) of losing his 25 diamond in a gold ring a month ago, and the resident stated that, you ( the Administrator) told Resident #8 the ring would be replaced. The Administrator denied every knowing Resident #8 had lost 25 diamond in a gold ring. The Administrator stated that they was unaware the Resident #8 had lost a diamond ring and they would fill out a concern form. The Administrator on 12/04/19 at 1:14 PM, was informed that Resident #8 has no inventory of personal effects form in his medical record. Therefore there is no way to determine whether Resident #8 had 25 diamonds in a gold ring while residing in the facility. The Administrator was informed that their policy stated a copy of the completed form is provided to the resident, another is placed in the resident medical record and a third copy is placed in the facility safe or a locked cabinet. The Business office Director( BOD) #93 and the Administrator confirmed they do not have any record of the inventory in their facility safe or locked cabinet. The Administrator stated that, he was aware the facility staff have been having problems completing an inventory of personal effects form on their residents. The Administrator, also acknowledged that Resident #70 did not have an inventory of personal effects form in her chart.",2020-09-01
478,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2019-12-05,880,E,0,1,QN1C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain an infection control program to help prevent the development and transmission of communicable disease and infection to the extent possible. This was related to improper hand-washing by a staff person prior to providing [MEDICAL CONDITION] for resident #187. Also, a staff person placed multiple-resident use equipment in her uniform pocket for transport. This had the potential to affect more than a limited number of residents. Resident Identifier #187. Facility census 91. Findings include: a) Resident #187 Observation of this resident's [MEDICAL CONDITION] care was conducted on 12/04/19 from 11:15 AM to 11:45 AM, as provided by licensed nurse #94 (LPN #94) and registered nurse #36 (RN #36). At the beginning, LPN #94 washed her hands in the resident's bathroom. After washing and rinsing her hands, she then used one of her freshly cleaned hands to touch the dirty faucet to turn off the water. She was told about this and agreed she should have turned the water off by using a paper towel to turn the faucet handle, as failure to do so contaminated her clean hand. She then rewashed her hands correctly. On three (3) instances during this observation RN #36 checked the resident's oxygen level with a portable pulse oximetry meter. This meter was placed on the resident's fingertip each time in order to obtain an oxygen level. She said this resident does not have a pulse oximetry meter specifically dedicated just for his use. Rather, multiple residents use the same meter. After each of three (3) checks of his pulse oximetry she placed the meter back into her left uniform pocket. It was discussed with her that recent infection control updates from the Centers for Disease Control and Prevention (CDC) speaks out against this practice of placing used personal care objects back into staff uniform pockets. She agreed, and stated this practice could potentially bring organisms back to the pocket and later be spread to other residents. An interview was conducted with the director of nursing (DON) and the administrator on 12/05/19 at 12:15 PM. The improper hand-washing technique and the improper transport of used multi-resident use care equipment was discussed. They acknowledged understanding. No further information was provided prior to exit.",2020-09-01
479,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2019-04-17,641,D,0,1,ZJL811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure assessments accurately reflect each residents' status. Resident #3's medication assessment inaccurately reflects anticoagulants and Resident #15's assessment lacks a [DIAGNOSES REDACTED]. Resident identifiers: #3 and #15. Facility census: 16. Findings included: a) Resident (R) #3 Review of the medical record on 04/16/19, revealed R #3's daily medications include aspirin 81 milligrams and [MEDICATION NAME] ([MEDICATION NAME] a platelet inhibitor) 75 milligrams daily and no anticoagulants. The quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 04/06/19 and the annual MDS assessment with an ARD of 07/13/18 are coded under section N0410E indicating R #3 received an anticoagulant daily during the seven (7) day look back period. During an interview on 04/17/19 at 9:10 AM, the Patient Care Coordinator / Licensed Practical Nurse (LPN) #12 reviewed R #3's MDS assessments and reported they were coded for anticoagulants because she was receiving [MEDICATION NAME] ([MEDICATION NAME]). LPN #12 stated she was unaware the MDS guidelines state not to code [MEDICATION NAME] as an anticoagulant. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.15, dated (MONTH) (YEAR) states under coding instructions for section N medications: [REDACTED]., [MEDICATION NAME], or low- molecular weight [MEDICATION NAME]): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, [MEDICATION NAME], or [MEDICATION NAME] ([MEDICATION NAME]) here. b) R15 During a medical record review for R15 on 04/17/19 revealed the Medium Data Set (MDS) quarterly assessment with the Assessment Reference Date ARD of 01/28/19 did not accurately include [MEDICAL CONDITION] as a [DIAGNOSES REDACTED]. Further review indicated R15 was receiving two (2) medications for [MEDICAL CONDITION]; [MEDICATION NAME] 0.15% ophthalmic solution 3 times daily, 1 drop in right eye for [MEDICAL CONDITION] and [MEDICATION NAME] 2% ophthalmic solution 3 times daily, 1 drop to right eye for [MEDICAL CONDITION] both had a start date of 12/09/18. In an interview on 04/16/19 at 11:30 AM, with E12, Patient Care Coordinator (PCC) verified the MDS for R15 did not include the [DIAGNOSES REDACTED].",2020-09-01
480,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2019-04-17,656,D,0,1,ZJL811,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to develop person-centered care plan for two (2) of fourteen (14) care plans reviewed during the investigation phase of the survey process. The care plan for R1 had not been developed for the [DIAGNOSES REDACTED]. Resident identifiers: R1 and R15. Facility census: 16. Findings included: a) R1 During a medical record review on 04/16/19 for R1 revealed the care plan had not been developed for the [DIAGNOSES REDACTED]. In an interview on 04/16/19 at 1:30 PM with E12 the Patient Care Coordinator (PCC) verified the care plan for R1 had not been developed for [MEDICAL CONDITION]. b) R15 During a medical record review on 04/16/19 for R15 the care plan had not been developed for the intervention of a non-pharmacological topical cream for pain. Further investigation included an order for [REDACTED]. In an interview on 04/16/19 at 1:35 PM with E12 the Patient Care Coordinator (PCC) verified the non-pharmacological topical cream had not been included as an intervention for pain for R15.,2020-09-01
481,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2019-04-17,657,D,0,1,ZJL811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to revise a care plans for two (2) of fourteen (14) care plans reviewed during the investigation phase of the survey process. The care plan for R1 had not been revised to reflect the dosage increase for [MEDICATION NAME] and for R15 the care plan had not been revised to include an assistive gait belt for fall prevention. Resident identifiers: R1 and R15. Facility census: 16. Findings included: a) R1 During a medical record review on 04/16/19 for R1 revealed the care plan had not been revised in the area of [MEDICAL CONDITION] Drug Use for a dosage increase of [MEDICATION NAME]. The physician's orders [REDACTED].>had been increased to 150 milligrams (mg) to be given nightly for a psychological disorder with a start date of 01/30/19. In an interview on 04/16/19 at 1:45 PM with E12 the Patient Care Coordinator (PCC) verified the care plan for R1 had not been revised to reflect the increase of [MEDICATION NAME] from 125 mg to 150 mg. b) R15 During a medical record review on 04/16/19 for R1 revealed the care plan had not been revised to include the assistive gait belt as an intervention for fall prevention. The care plan for R15 had been revised for a fall on 04/09/19, but did not include the physician's orders [REDACTED]. In an interview on 04/16/19 at 1:30 PM with E12 the Patient Care Coordinator (PCC) verified the care plan for R15 had not been revised to include the assistive gait belt as an intervention for falls. E12 also stated she reviews all new orders every Friday and this order had been missed.",2020-09-01
482,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2019-04-17,684,D,0,1,ZJL811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to provide needed care and services in accordance with resident's preferences, goals and to provide professional standard of practice to promote resident's physical, mental and psychosocial needs. This was true for one (1) of five (5) residents reviewed for Unnecessary Medications. R1 did not receive the medication [MEDICATION NAME] as ordered. Resident identifier: R1. Facility census: 16. Findings included: a) R1 During a medical record review on 04/16/19 it was discovered R1 had not received the medication [MEDICATION NAME] as ordered. The physician's orders [REDACTED]. Further investigation of the Medication Administration Record [REDACTED]. --7 of 15 doses not administered with breakfast --8 of 15 doses not administered with lunch --15 of 15 doses not administered with dinner --15 of 15 doses given correctly with a snack In an interview with the Director of Extended Care Services on 04/16/19 at 3:20 PM verified R1 had received 30 doses of [MEDICATION NAME] without food.",2020-09-01
483,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2019-04-17,726,E,0,1,ZJL811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to ensure staff had the competencies and skill sets to provide care to residents as needed. Staff failed to perform proper hand hygiene and incontinence care. This practice has the potential to affect more than a limited number of residents. Facility census: 16. Findings included: a) Hand hygiene During a medication administration observation at 04/16/19 8:25 AM, Licensed Practical Nurse (LPN) #19 administered medications to Resident (R) #3, washed her hands for less than five seconds and returned to the medication cart to continue passing medications to other residents. During an interview immediately after this observation, LPN #19 reported reported the facility policy is to wash hands for a minimum of 20 seconds, and agreed washing her hands for only five (5) seconds increases the resident's risk for infection. The facility policy titled Hand Hygiene with a revision date of 04/2018, states under the procedure section: .Continue rubbing your hands for at least 20 seconds . The above observation was reviewed with the Director of the Extended Care Unit / Registered Nurse (RN) #11 on 04/16/19 at 11:15 AM. RN #11 agreed these concerns were breeches in infection control. b) Incontinence care During an observation on 04/16/19 at 10:44 AM, Nurse Aide (NA) #27 repositioned Resident (R) #8 on her right side, placed multiple wash cloths in the unclean sink basin and turned on the faucet. NA #27 donned clean gloves, grabbed one wash cloth at a time from the sink and cleaned the liquid stool off of R #8's buttocks. NA #27 placed the soiled cloths on top of the laundry hamper, turned the faucet off with her soiled gloved hand, and preceded to the other side of the bed without changing gloves and/or washing her hands. NA #27 repeatedly touched the upper bed rail and held R #8 while the Licensed Practical Nurse (LPN) #19 performed wound care. NA #27 then assisted with repositioning R #8 before removing her gloves and washing her hands. During an interview immediately after this observation, NA #27 reported hands should be washed immediately after removing gloves and added she forgot to change her gloves and wash her hands after completing incontinence care. LPN #19 and NA #27 agreed laying wash cloths in the sink basin and using them on the resident is not a sanitary practice and exposes the resident to infection. On 04/16/19 at 1:05 PM, NA #22 and NA #21 were observed completing incontinence care. Resident (R) #5 was repositioned and draped for perineal care. NA #21 wet washcloths in a basin, retrieved one cloth at a time and applied [MEDICATION NAME] body wash. NA #21 cleaned R #5's lower abdomen, then swiped down front to back on the right side of the perineum, the left side of the perineum and then the middle using the same area of the wash cloth. With a second wash cloth, NA #21 repeated the same sequence using the same section of the washcloth, then dried the resident's skin. NA #21 and NA #22 assisted R #5 with turning to her left side. NA #21 cleaned R #5's bottom in a front to back manner, dried the resident and then assisted with repositioning R #5 without changing her gloves and/or washing her hands. Immediately after this observation, NA #21 acknowledged she was unaware the standard of care is to use a different section of the washcloth with each swipe of the perineum. NA #21 agreed she should have changed her gloves prior to repositioning the resident. The above observations were reviewed with the Director of the Extended Care Unit / Registered Nurse (RN) #11 on 04/16/19. RN #11 agreed these concerns were breeches in infection control and stated an inservice would be conducted immediately. The facility policy titled Hand Hygiene with a revision date of 04/2018, states under the procedure section: Hand hygiene with either waterless hand sanitizer or soap and water is requires .after removing gloves .Before moving to a clean body site from a contaminated body site during patient care .After contact with body fluids . The facility policy titled Bed Bath with a revision date of 04/2018, states under the procedure section: .bathe the genital area .using a different section of the washcloth for each downward stroke .",2020-09-01
484,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2019-04-17,812,E,0,1,ZJL811,"Based on observations and staff interview it was found that the dietary staff have not always ensured the dietary staff have handled food in a manner that maintains sanitary conditions. Food and non-food items were handled by staff using the same gloves. This practice has the potential to affect more than a limited number of residents who consume food by oral means that are served from this central location. Census: 16. Findings include: a) On 04/16/19 10:19 AM dietary observations were conducted shortly after the entrance . The dietary manager accompanied the surveyor at the time. It was noted the dietary staff member used the same gloves to handle food then non-food items and then back to food items. He used gloves to handle rolls for sandwiches, touch lids and other non-food items , then so back to handling foods. This was discussed again with the dietary manager about the staff member using the same gloves for food/non-food at 12:45 p.m. on 04/4/6/19.",2020-09-01
485,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2019-04-17,880,F,0,1,ZJL811,"**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 Prevention and Control Program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infections. Staff failed to perform proper hand hygiene and perineal care, and failed to provide/maintain a barrier for multi dose medication bottles during medication administration. This practice has the potential to affect all residents residing in the facility. Facility census: 16. Findings included: a) Perineal care During an observation on 04/16/19 at 10:44 AM, Nurse Aide (NA) #27 repositioned Resident (R) #8 on her right side, placed multiple wash cloths in the unclean sink basin and turned on the faucet. NA #27 donned clean gloves, grabbed one wash cloth at a time from the sink and cleaned the liquid stool off of R #8's buttocks. NA #27 placed the soiled cloths on top of the laundry hamper, turned the faucet off with her soiled gloved hand, and preceded to the other side of the bed without changing gloves and/or washing her hands. NA #27 repeatedly touched the upper bed rail and held R #8 while the Licensed Practical Nurse (LPN) #19 performed wound care. NA #27 then assisted with repositioning R #8 before removing her gloves and washing her hands. During an interview immediately after this observation, NA #27 reported hands should be washed immediately after removing gloves and added she forgot to change her gloves and wash her hands after completing incontinence care. LPN #19 and NA #27 agreed laying wash cloths in the sink basin and using them on the resident is not a sanitary practice and exposes the resident to infection. On 04/16/19 at 1:05 PM, NA #22 and NA #21 were observed completing incontinence care. Resident (R) #5 was repositioned and draped for perineal care. NA #21 wet washcloths in a basin, retrieved one cloth at a time and applied [MEDICATION NAME] body wash. NA #21 cleaned R #5's lower abdomen, then swiped down front to back on the right side of the perineum, the left side of the perineum and then the middle using the same area of the wash cloth. With a second wash cloth, NA #21 repeated the same sequence using the same section of the washcloth, then dried the resident's skin. NA #21 and NA #22 assisted R #5 with turning to her left side. NA #21 cleaned R #5's bottom in a front to back manner, dried the resident and then assisted with repositioning R #5 without changing her gloves and/or washing her hands. Immediately after this observation, NA #21 acknowledged she was unaware the standard of care is to use a different section of the washcloth with each swipe of the perineum. NA #21 agreed she should have changed her gloves prior to repositioning the resident. The above observations were reviewed with the Director of the Extended Care Unit / Registered Nurse (RN) #11 on 04/16/19. RN #11 agreed these concerns were breeches in infection control and stated an inservice would be conducted immediately. The facility policy titled Hand Hygiene with a revision date of 04/2018, states under the procedure section: Hand hygiene with either waterless hand sanitizer or soap and water is requires .after removing gloves .Before moving to a clean body site from a contaminated body site during patient care .After contact with body fluids . The facility policy titled Bed Bath with a revision date of 04/2018, states under the procedure section: .bathe the genital area .using a different section of the washcloth for each downward stroke . b) Medication administration During a medication administration observation at 04/16/19 8:25 AM, Licensed Practical Nurse (LPN) #19 entered Resident (R) #3's room to administer morning meds. LPN #19 placed the Unmeclidinium [MEDICATION NAME] inhaler, the Muro multi dose eye drop container, the Acestitine nasal spray bottle and the Breo Elipta inhaler directly on the bedside table next to Resident (R) #3's personal items, while she administered R #3's oral meds. LPN #19 washed her hands for less then 5 seconds, collected the four (4) multidose containers and returned them to the top of the medication cart. LPN #19 unlocked the med cart and placed the multidose containers of Unmeclidinium [MEDICATION NAME], eye drops, nasal spray and Breo inhaler into their original containers and back into the cart. During an interview immediately after this observation, LPN #19 reported she was unaware of the need to use a barrier between multi dose vials and the bedside table. In addition, LPN #19 reported the facility policy is to wash hands for a minimum of 20 seconds, and agreed washing hands five (5) seconds increases the resident's risk for infection. The facility policy titled Hand Hygiene with a revision date of 04/2018, states under the procedure section: .Continue rubbing your hands for at least 20 seconds . The above observations were reviewed with the Director of the Extended Care Unit / Registered Nurse (RN) #11 on 04/16/19 at 11:15 AM. RN #11 agreed these concerns were breeches in infection control.",2020-09-01
486,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2017-05-09,280,D,0,1,KOWR11,"**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 for Resident #8 when there was a change in an antibiotic medication regimen. This practice was found for one (1) of fourteen (14) Stage 2 sample residents whose care plan was reviewed during the Quality Indicator Survey (QIS). Resident Identifier: #8. Facility census: 16. Findings include: a) Resident #8 A review of Resident 38's medical record, at 2:26 p.m. on 05/09/17, found a physician's orders [REDACTED]. The care plan for Resident #8 was silent for goals and interventions related to the antibiotic medication Bactrim. After reviewing the care plan on 05/09/17 at 3:22 p.m., Registered Nurse (RN) #26 verified the care plan did not contain goals and interventions related to the antibiotic medication Bactrim. She stated , I will check with my co-worker the other Minimum Data Set (MDS) nurse to see if she can find anything. RN #26 reported on 05/09/17 at 3:30 p.m. It just got missed (the antibiotic medication Bactrim) when it was restarted.",2020-09-01
487,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2017-05-09,371,F,0,1,KOWR11,"Based on observation and staff interview, the facility failed to store and serve foods in a safe and sanitary manner. The kitchen walk-in refrigerator had undated and unsecured food items, and un-intact frozen food items in the walk-in freezer. This practice has the potential to affect all residents. Facility census: 16. Findings include: During a tour of the kitchen on 05/09/17 at 8:00 a.m. accompanied by Dietary employee #55 discovered in the kitchen walk-in refrigerator an undated unsecured plastic bag of cooked corn beef slices and undated unsecured plastic bag of white cheese cubes. In the kitchen walk-in freezer found an unsecured undated plastic bag of crinkle cut french fries. At the conclusion of the tour, Dietary employee #55 immediately disposed of the previous food items. He stated, all opened food items are to dated when they are open for use and always to be secured with a twist tie or tied to ensure they are always closed, otherwise no one knows when they were opened. I have a meeting every morning at 10:30 a.m. and this is something I always stress to date and secure food items.",2020-09-01
488,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2017-05-09,441,F,0,1,KOWR11,"**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 designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. An employee failed to perform hand hygiene during tray pass to residents' in their rooms during a heightened alert for upper respiratory symptoms. This practice has the potential to affect all residents residing on the unit. Facility census: 16. Findings include: a) During an observation of the lunch meal pass, on 05/08/17 at 12:07 p.m., Dietary employee #20 entered the unit with the food cart and began passing trays without sanitizing and/or washing her hands. Employee #20 touched the bedside table when she carried a tray into room [ROOM NUMBER] and placed the tray onto Resident #7's table. She exited the room without washing and/or sanitizing her hands and returned to the meal cart. Employee #20 carried a tray into room [ROOM NUMBER] marked with a sign saying Please see nurse before entering, repositioned three (3) cups sitting on Resident #4's bedside table, set the tray down on the table and exited the room without washing and/or sanitizing her hands. Dietary employee #20 retrieved a third tray form the meal cart and entered room [ROOM NUMBER] marked with the signage Please see nurse before entering, and placed the tray on Resident #6's bed side table and exited the room without any attempts to wash and/or sanitize her hands. During an interview immediately after this observation, Employee #20 acknowledged she had not washed and/or sanitized her hands between tray passes and stated There is no hand sanitizer in the halls like on the other floors. During an interview at 12:15 p.m., on 05/08/17, Licensed Practical Nurse (LPN) #33 reported all staff are to wash and/or sanitize their hands between residents. Each resident room contains a wall mounted hand sanitizer as well as a sink with soap. LPN #33 acknowledged this was an infection control concern especially with the current upper respiratory outbreak on the unit. Licensed Practical Nurse (LPN) #27 was interviewed on 05/08/17 at 1:23 p.m., she reported some of the residents were experiencing upper respiratory symptoms and all meals were being served in the residents' rooms because of a concern related to the virus. The signage stating Please see nurse before entering was posted on the residents' doors to remind staff to practice good hand hygiene and to deter visitors from visiting multiple residents. LPN #27 noted there were signs on Rooms #323, 324, 327, 329, and 330. The facility policy titled Hand Hygiene, IC (3/15) states under Hand Hygiene indications: Hand hygiene with either waterless hand sanitizer or soap and water is required: a. Upon entering and leaving a patient room or environment .l. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.",2020-09-01
489,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2018-05-09,577,C,0,1,VZPJ11,"Based on resident interviews during the Resident Council meeting and staff interviews, the facility failed to post in a place readily accessible to residents, family members and legal representatives, the most recent state inspection survey results of the facility. This had the potential to affect all individuals wanting to review the results of survey and any plan of correction for this facility. Facility census: 16. Findings included: a) Posting survey results During the Resident Council meeting on 05/09/18 at 10:00 AM, the resident council members did not know the state inspection was to be made available for them to review, nor did they know where it was located in the facility. Explained the results of the most recent survey and any plan of correction was to be posted and readily accessible for them and their family members to review. In an interview with Employee #31, social services director on 05/09/18 at 10:25 AM, verified the state inspection survey results were not posted and readily accessible to residents, family members or visitors.",2020-09-01
490,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2018-05-09,656,D,0,1,VZPJ11,"Based on observations, medical record review and staff interview, the facility failed to develop and implement a comprehensive care plan for the use of a seat belt alarm restraint for Resident #5. This was true for one (1) one of (1) one residents reviewed for use of physical restraints. Resident identifier: #5. Facility census: 16. Findings included: a) Resident #5 On 05/08/18 at 10:56 AM, during a observation of Resident #5 it was discovered she had a seat belt alarm restraint activated across her waist while she was in a wheelchair. A review of the medical record on 05/08/18 revealed the comprehensive care plan written on 05/02/18 did not address the use of a physical restraint. Interventions must include medical symptoms to justify the use of the restraint, type of restraint, frequency, duration, circumstances for when to be used, and assessment for less restrictive alternatives, also interventions to address potential or actual complications from restraint use such as: increased incontinence, decline in activity of daily living (ADL) or range of motion (ROM), increased confusion, agitation or depression. During interviews with the director of nursing (DON) and Minimum Data Set (MDS) Coordinator on 05/09/18 at 9:30 AM, verified the comprehensive care plan for Resident #5 did not address physical restraints or interventions for using a seat belt alarm restraint.",2020-09-01
491,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2018-05-09,657,D,0,1,VZPJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise residents' care plans when conditions or interventions changed. Resident #1 continued to have a care plan for monitoring administration of an anticoagulant medication that was discontinued on 3/25/18, and Resident #10's care plan was not revised to include bilateral contractures of shoulders and hands. This was found for two (2) of thirteen (13) residents reviewed. Resident identifiers: #1, #10. Facility census: 16. Findings included: a) Resident #1 Review of the care plan for Resident #1 on 5/9/18 at 9:00 AM found an active problem for risks of adverse side effects due to daily use of the anticoagulant [MEDICATION NAME]. The goal was to prevent excessive bleeding or bruising by monitoring the resident closely. Review found the medication had been ordered by the Physician for seventeen (17) doses, beginning on 3/9/18 and ending on 3/25/18. An interview was conducted with Registered Nurse (RN) #11 on 5/9/18 at 9:30 AM. She agreed the care plan should have been revised to remove the problem when the final dose of the anticoagulant was stopped on 3/25/18. b) Resident #10 A medical record review for Resident #10 on 05/09/18 revealed the quarterly Minimum Data Set (MDS) with assessment reference date of 02/28/18 reported this resident to have contractures to both hands, both shoulders and both hips. The care plan was not revised to include contractures to both hands and both shoulders under the activity of daily living (ADL) functioning problem. In an interview with the director of nursing (DON) on 05/09/18 at 10:55 AM, verified the care plan had not been revised to include all the contractures for Resident #10.",2020-09-01
492,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2018-05-09,726,F,0,1,VZPJ11,"Based on observation and staff interview, the facility failed to ensure licensed nurses have the specific competencies and skills sets to provide nursing and related services to each resident. Staff failed to provide wound care according to professional standards of care and to maintain and/or implement effective infection control standards. This practice has the potential to affect all residents. Resident identifier: #11. Facility Census: 16. Findings included: a) Resident #11 On 05/09/18 at 1:45 PM, observations of wound care performed by Licensed Practical Nurse (LPN) # 19 in the accompaniment of the Director of Nursing (DON) revealed the following: --LPN #19 placed a clean disposable pad on the unclean bedside table next to the resident's cup and water pitcher. She then placed wound care supplies and dressings on the pad. --LPN #19 washed her hands and donned clean gloves. --LPN #19 removed the left buttocks dressing and packing and placed them directly on the resident's bed next to her lower legs (not in a designated trash bag). --LPN #19 squirted 1/2 of a 10 milliliter (ml) saline syringe into the 5 centimeter (cm) by 4 cm by 1.5 cm hole and proceeded to dry the outer wound edges with one 4 by 4 gauze. She then placed the soiled gauze on the bed next to the soiled dressing. --Without performing hand hygiene and changing her gloves, LPN #19 tore a corner off an Algisite pad (textile fiber used in wound care), pushed the Algisite into the wound with her finger, and applied a clean dressing. --LPN #19 discarded the soiled dressing, packing, gauze and her gloves into the resident's trash can. --The resident began to pass stool during this dressing change. No attempts were made to cover the area or to stop and perform incontinence care. --LPN #19 washed her hands, donned clean gloves, and moved to the other side of the bed. --The resident was repositioned on her left side by the DON and LPN #19. Traces of stool were noted on the bed linen. --LPN #19 removed the dressing and packing from the right buttocks and placed them directly on the bed sheet adjacent to the resident's lower legs. --The 6 cm by 6 cm by 2 cm wound was cleansed with one 10 ml syringe of saline and the outer wound edges dried with one 4 by 4 gauze. --The syringe and soiled gauze were placed on the bed near the soiled dressing. --LPN #19 repacked the wound and applied a clean dressing without performing hand hygiene and donning clean gloves. These findings were reviewed with Registered Nurse (RN) #35 during an interview immediately following these observations. RN #35 acknowledged LPN #19 failed to maintain and implement effective infection control practices during wound care.",2020-09-01
493,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2018-05-09,812,E,0,1,VZPJ11,"Based on observation and staff interview, the facility failed to properly store and prepare food in a safe and sanitary manner. During the kitchen tour it was discovered opened and not dated foods in the walk-in freezer and refrigerator. Also the drip pans to the stove and grill were dirty and in need of cleaning. This had the potential to affect all receiving nutrition from the kitchen. Facility census: 16. Findings included: a) Kitchen tour During the kitchen tour on 05/08/18 at 8:05 AM, it was discovered in the walk-in freezer a 40 ounce (oz) bag of smoked gouda cheese bites, five (5) boneless pork chops, 32 oz bag of mixed vegetables, and a 40 oz bag of ravioli were opened and not dated. In the walk-in refrigerator there was a container of mushrooms not dated after opening. Also the drip pans for the stove and grill were dirty and in need of cleaning. The dietary manager was present during the tour of the kitchen on 05/08/18 at 8:05 AM and verified all the foods were opened and not dated in the walk-in freezer and refrigerator and she was made aware of the dirty drip pans.",2020-09-01
494,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2018-05-09,842,D,0,1,VZPJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain a complete and accurate medical record for Resident # 5. The physician order [REDACTED]. This was true for one (1) of thirteen (13) medical records reviewed during the survey process. Resident identifier: #5. Facility census: 16. Findings included: a) Resident #5 A review of the medical record for Resident #5 on 05/09/18 revealed the current physician orders [REDACTED]. The physician order [REDACTED]. In an interview with the director of nursing (DON) on 05/09/18 at 9:30 AM, verified the physician order [REDACTED].#5.",2020-09-01
495,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2018-05-09,867,F,0,1,VZPJ11,Deficiency Text Not Available,2020-09-01
496,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2018-05-09,880,F,0,1,VZPJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility record review and staff interview, the facility failed to maintain an effective Infection Prevention and Control Program (IPCP) designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infections. Facility tracking and trending logs lack identifiable information related to specific organism, treatment, and/or preventable measures to decrease infections. Staff failed to clean wounds and change dressings in a safe and sanitary manner. This practice has the potential to affect all residents residing in the facility. Resident identifiers: #11. Facility census: 16. Findings included: a) Tracking and Trending Infections Review of the medical record on 5/08/18, revealed Resident #11 had positive urinary cultures on 10/13/17, 03/27/18 and 04/30/18 for [DIAGNOSES REDACTED] pneumonia (a gram-negative anaerobic bacterium often resistant to multiple organisms). All three cultures were treated with antibiotics. The record lacks any information related to utilization tools used to determine if Resident #11 met the minimum criteria for the initiation of antibiotics. The infection control tracking / antibiotic use log identifies Resident #11's urinary tract infections (UTIs) on 10/13/17, 03/27/18 and 04/30/18. The tracking log does not note Resident #11's chronic indwelling catheter, nor the organism and sensitivity for appropriate antibiotic treatments. The infection control tracking log was reviewed during an interview on 05/08/18 at 8:45 AM, with the Director of Nursing (DON) #11 and the Infection Control Nurse / Registered Nurse (RN) #8. Both nurses reported the Antibiotic Stewardship protocols were developed, but no attempts have been made to implement them. The DON acknowledged she completes the Infection Control Tracking / Antibiotic Use form which lacks the organisms identified in the culture results, treatments provided other than antibiotics, and/or identified preventable measures. b) Wound care On 05/09/18 at 1:45 PM, observations of wound care performed by Licensed Practical Nurse (LPN) # 19 in the accompaniment of the Director of Nursing (DON) revealed the following: --LPN #19 placed a clean disposable pad on the unclean bedside table next to the resident's cup and water pitcher. She then placed wound care supplies and dressings on the pad. --LPN #19 washed her hands and donned clean gloves. --LPN #19 removed the left buttocks dressing and packing and placed them directly on the resident's bed next to her lower legs (not in a designated trash bag). --LPN #19 cleansed the wound and placed the soiled gauze on the bed next to the soiled dressing. --Without performing hand hygiene and changing her gloves, LPN #19 tore a corner off of an Algisite pad (textile fiber used in wound care), pushed the Algisite into the wound with her finger, and applied a clean dressing. --LPN #19 discarded the soiled dressing, packing, gauze and her gloves into the resident's trash can. --The resident began to pass stool during this dressing change. No attempts were made to cover the area or to stop and perform incontinence care. --LPN #19 washed her hands, donned clean gloves, and moved to the other side of the bed. --The resident was repositioned on her left side by the DON and LPN #19. Traces of stool were noted on the bed linen. --LPN #19 removed the dressing and packing from the right buttocks and placed them directly on the bed sheet adjacent to the resident's lower legs. --The wound was cleansed and the outer edges dried with one 4 by 4 gauze. --The soiled gauze was placed on the bed by the soiled dressing. --LPN #19 repacked the wound and applied a clean dressing without performing hand hygiene and donning clean gloves. These findings were reviewed with Registered Nurse (RN) #35 during an interview immediately following these observations. RN #35 acknowledged LPN #19 failed to maintain and implement effective infection control practices during wound care.",2020-09-01
497,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2018-05-09,881,F,0,1,VZPJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility's Infection Control Prevention Team (ICPT) failed to develop an Antibiotic Stewardship program that promotes the appropriate use of antibiotics. Actions were not implemented to improve antibiotic use and reduce adverse events associated with antibiotics, including the development of antibiotic-resistant organisms. Antibiotic use protocols and assessment tools were not initiated and utilized prior to the prescribing and administration of antibiotics. Facility tracking and trending logs lack identifiable information related to specific organism, treatment, and/or preventable measures to decrease urinary tract reoccurrence for Resident #11. This practice has the potential to affect all residents residing in the facility. Resident identifier: #11. Facility census: 16. Findings included: a) Resident #11 Review of the medical record on 5/08/18, revealed Resident #11 is a wheel chair dependent diabetic, with a history of stroke, and repeated urinary tract infections (UTIs) with an indwelling urinary catheter. The acute care history and physical note dated 2013, identifies Resident #11's chronic urinary catheter with urinary tract infection verses colonization. Urinary cultures on 10/13/17, 03/27/18 and 04/30/18 were positive for [DIAGNOSES REDACTED] pneumonia (a gram-negative anaerobic bacterium often resistant to multiple organisms). All three cultures were treated with antibiotics. The record lacks any information related to utilization tools used to determine if Resident #11 met the minimum criteria for the initiation of antibiotics. The infection control tracking / antibiotic use log identifies Resident #11's UTIs on 10/13/17, 03/27/18 and 04/30/18. The tracking log does not note Resident #11's chronic indwelling catheter, nor the organism and sensitivity for appropriate antibiotic treatments. The infection control tracking log and Antibiotic Stewardship policies were reviewed during an interview on 05/08/18 at 8:45 AM, with the Director of Nursing (DON) #11 and the Infection Control Nurse / Registered Nurse (RN) #8. Both nurses reported the Antibiotic Stewardship protocols were developed, but no attempts have been made to implement them. RN #8 reported the physicians carry an Antibiotic Stewardship Handbook which identifies which antibiotic to use for each identified illness. RN #8 agreed the book lacks any information related to screening residents prior to the initiation of antibiotics to determine if they meet the minimum criteria for the initiation of antibiotics in long term care residents, based on the current Center for Disease Control and Prevention (CDC) guidelines. In addition, the infection control nurse / RN #8 acknowledged Resident #11's repeated [DIAGNOSES REDACTED] pneumonia urine cultures may be related to an actual bacterial colonization of the urinary tract and not require repeated treatments with antibiotics. The policy titled Antibiotic Stewardship with a revision date of 09/2017, states: Antimicrobial misuse and overuse has the unintended consequence of adverse events and the development of multi-drug resistant organisms (MRDOs). The medical staff of (name) has a responsibility to prescribe in accordance with current CDC (Centers for Disease Control) guidelines for the prevention of MRDOs . Section 4 of the procedure states: Medical staff should avoid the use of antibiotics in patients with suspected [MEDICAL CONDITION] or noninfectious illnesses as a strategy to reduce the use of unnecessary antimicrobial orders.",2020-09-01
498,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,578,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the resident's advance directives, communicated via the Physician order [REDACTED]. Resident identifier: #38. Facility census: 100. Findings included: a) Resident #38 Review of the medical record found the Resident lacked capacity to make medical decisions, and her son was her legal representative. Review of the current POST form noted the Resident did not wish to be resuscitated, have comfort measures, a feeding tube, or IV fluids for a trial period of no longer than 3-5 days. Under the heading, signature of Patient/Resident, the form noted verbal consent was obtained from (Name of son) via phone on 09/29/19. The physician signed the POST form on 08/01/19, although the POST form indicated the Resident's son did not complete the form until 09/29/19. The date the form was prepared by a facility nurse was 07/29/19. The resident's electronic medical record as well as the current care plan directed, do not attempt resuscitation, or comfort measures. Review of the instructions for the 2016 edition entitled, Using the POST form, section D, found: The patient or representative/surrogate and physician/APRN (Advanced Practice Registered Nurse) must sign the form in this section. These signatures are mandatory. A form lacking these signatures is NOT valid. The physician/APRN then prints his/her name, phone number, and the date and time the orders were written. On 01/29/20 at 10:10 AM, the facility social worker (SW) #81 verified the Resident's son did not sign the POST form. SW #81 said she did not know anything about the POST form because she was not present when the POST form was completed. The POST form was discussed with the administrator at 8:06 AM on [DATE]. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
499,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,580,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record interview and interview, the facility failed to notify the physician when medications were held for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #98. Facility census: 100. Findings included: a) Resident #98 Review of Resident #98's medical records found the resident was ordered to receive [MEDICATION NAME] 5/325 milligrams (mg) via the feeding tube three times daily for pain and [MEDICATION NAME] 0.25 mg via feeding tube three times a day for anxiety. Review of Resident #98's nurses progress notes found on 10/31/19 at 6:55 PM, a Licensed Practical Nurse (LPN) #138 held the [MEDICATION NAME] and [MEDICATION NAME]. Note attached to the holding of [MEDICATION NAME] and [MEDICATION NAME] as follows: Medication held due to drowsiness, spoke with son and he was also in agreement to hold the medication. There was no documentation the physician was notified of the withholding of the medication. During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 02/03/20 at 1:15 PM, they verified after reviewing the medical records for Resident #98, the physician had not been notified of the withholding of [MEDICATION NAME] and [MEDICATION NAME] on 10/31/19. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
500,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,584,D,0,1,CN2N11,"Based on record review and interview, the facility failed to ensure reasonable care for the protection of resident's personal property from loss or theft for one (1) of one (1) resident reviewed for the care area of personal property. Resident identifier: #58. Facility census: 100. Findings included: a) Resident #58 On 0[DATE] 03:01 PM, the Resident's son said he had no problems with the facility other than, They lose clothes in laundry sometimes they find them, sometimes not. It's just aggravating not a big problem. I have been labeling them myself. Sometimes they don't label them, and I think that is what causes the problem. Review of the notes in the electronic medical record found a progress note, dated 06/27/19 at 9:14 AM, during a care conference for the resident, his son raised his concern that his mother had some articles of clothing that are missing. At 11:44 AM on 01/28/20, the Social Worker (SW) #33 confirmed she could not find information to indicate the investigation into the allegation of missing clothing. SW #33 said someone at the facility should have completed a complaint form, then this allegation would have been assigned to someone in environmental services. She said if an item is missing and we can confirm the Resident had the item, the facility would reimburse the family member or replace the missing item. At 8:06 AM on [DATE], the Administrator was informed of the above information. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
501,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,623,D,0,1,CN2N11,"Based on record review and staff interview, the facility failed to provide the Ombudsman with notification of a resident's transfer to the hospital for one (1) of two (2) residents reviewed for the care area of hospitalization . Resident identifier: #[AGE]. Facility census: 100. Findings included: a) Resident #[AGE] A record review for Resident #[AGE] on 01/28/20, revealed two (2) Minimum Data Sets dated [DATE] and 12/24/20 for transfer to an acute care hospital. Further review indicated there had been no notifications of these hospitalization s sent to the Ombudsman. On 02/03/20 at 1:52 PM, the Nursing Home Administrator (NHA) verified there were no notices sent to the Ombudsman for hospitalization s on [DATE] and 12/24/19. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
502,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,641,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) for three of 20 residents. Resident identifiers: #99, #38, #98. Facility census: 100. Findings included: a) Resident #99 Review of Resident #99's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 01/12/20, stated the resident had two (2) Stage 2 pressure ulcers. Resident #99's Pressure Ulcer Reassessment dated [DATE], documented a Stage 4 pressure ulcer on the left buttock. An initial Pressure Ulcer Assessment also performed on 01/07/20 documented a new unstageable pressure ulcer on Resident #99's sacrum. Resident #99's Pressure Ulcer Reassessments dated 01/14/20 documented a Stage 4 pressure ulcer on the left buttock and a Stage 3 pressure ulcer on the left buttock. During an interview on 02/03/20 at 11:46 AM, the Regional Director of Operations stated Resident #99's MDS with ARD 1/12/20 was incorrect. She stated Resident #99 did not have two (2) Stage 2 pressure ulcers at that time. No further information was provided through the completion of the survey. b) Resident #38 Review of Resident's quarterly, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/19, coded the resident as receiving an anticoagulant for 2 days during the assessment period. Review of the Medication Administration Record [REDACTED]. At 2:26 PM on 01/29/20, during an interview with the nursing coordinator #139, it was confirmed the MDS was incorrectly coded, and the resident did not receive an anticoagulant. c) Resident #98 Review of the Resident's medical record found a comprehensive (5-day) minimum data set (MDS) with an assessment reference date (ARD) of [DATE], coded as the Resident received a hypnotic medication. Review of the November 2019, physician orders [REDACTED]. At 01/31/20 at 12:54 pm, the MDS registered nurse employee #139, confirmed the MDS was incorrect. In addition, E #139 confirmed the resident was not ordered a hypnotic. E #139 said she would correct this MDS error. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
503,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,656,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a person-centered comprehensive care plan for one of twenty (20) residents reviewed. The care plan for Resident #57 was not developed for the [DIAGNOSES REDACTED].#57. Facility census: 100. Findings included: a) Resident #57 A record review on 01/29/20, revealed the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/20/20, indicated the Resident had a [DIAGNOSES REDACTED]. During an interview on 01/29/20 at 11:15 AM, the Director of Nursing (DON) verified the care plan had not been developed for the [DIAGNOSES REDACTED].#57. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
504,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,657,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to revise the comprehensive care plan for one of 20 residents reviewed. Resident identifier: #17. Facility census: 100. Findings included: a) Resident #17 Review of Resident #17's comprehensive care plan revealed the following focus, (Resident's name) has an ADL Self Care Performance Deficit r/t (related to) stroke, left [MEDICAL CONDITION]. Interventions included, Bathing: The resident requires 1 staff participation with bathing.Resident receives a shower on Monday/Thursday and a bed bath the remaining days. Review of Resident #17's task report for January 2020, revealed she received showers on Tuesdays and Fridays. During an interview on 01/29/20 at 9:49 AM, the Director of Nursing (DON) verified Resident #17 received showers on Tuesdays and Fridays, but her care plan stated she received showers on Mondays and Thursdays. The DON stated she would update the care plan to reflect Resident #17 received showers on Tuesdays and Fridays. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
505,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,684,E,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure one (1) of five (5) residents discharged from the facility received treatment and care in accordance with professional standards of practice. Nursing staff failed to follow physician's orders [REDACTED]. Resident identifier: #103. Facility census: 100. Findings included: a) Resident #103 Record review found the Resident was admitted to the facility on [DATE]. The Resident was discharged to home on 07/12/19. On 06/25/19 the physician wrote an order for [REDACTED].>Accu-Check ac and hs; notify FNP (family nurse practioner) or MD ( if greater than 350 or less than [AGE]. before meals and at bedtime. This order remained in effect until the Resident was discharged on [DATE]. Review of the Medication Administration Record [REDACTED]. On the following dates and times, the Resident's blood sugar (BS) was over 350 and the physician was not notified: --06/25/19 at 9:00 PM, BS- 392 --06/26/19 at 11:30 AM, BS - 399 --06/26/19 at 5:30 PM, BS - 387 --06/26/19 at 9:00 PM, BS - 400 --06/27/19 at 11:30 AM, BS 396 --06/27/19 at 5:30 PM, BS - 3[AGE] --06/28/19 at 11:30 AM, BS - 371 --07/01/19 at 5:30 PM, BS - 390 --07/02/19 at 9:00 PM, BS - 392 --07/03/19 at 5:30 PM, BS - 389 --07/03/19 at 9:00 PM, BS - 399 --07/06/19 at 9:00 PM, BS - 370 --07/07/19 at 9:00 PM, BS - 367 --07/09/19 at 11:30 AM, BS - 366 --07/11/19 at 9:00 PM, BS - 394 On 15 occasions during the resident's 19 day stay at the facility the Resident's BS was over 350 and the physician was not notified. In addition the Resident's blood sugar was over 400 on two (2) occasions when the physician was contacted. On 06/25/19 the physician was contacted for a blood sugar reading of 404 at 5:30 PM. New orders were written to start sliding scale [MED] ([MEDICATION NAME]) for 7 days and give 10 units of [MEDICATION NAME] at this time. Sliding scale [MED] was to be administered per sliding scale at 7:30 AM, 11:30 AM, 5:30 PM and 9:00 AM. There was no indication on the MAR indicated [REDACTED]. This new order noted the physician should be contacted when BS was over 400. However, the original order continued on the MAR indicated [REDACTED]. On 07/06/19 a new order was written to give [MEDICATION NAME] solution 100 unit/ML, sliding scale at 9:00 AM and 9:00 PM. On 07/06/19 at 9:00 PM the BS was recorded as 387 under this order. But at the same time the Resident's BS was recorded to be 370 on another order at 9:00 PM. At 2:00 PM on 01/28/20, during an interivew with the Director of Nursing (DON) reviewed the MAR's with the surveyor. The DON confirmed the facility did not notify the physician when the resident's BS was over 350 on 15 occasions as directed by the order on the MAR. The DON was unable to find evidence the Resident received 10 units of [MEDICATION NAME] at 5:30 PM on 06/25/19. The DON said a onetime order should have been written to give the 10 units of [MEDICATION NAME] at 5:30 PM on 06/25/19. On 02/03/20 03:59 PM, the Resident's physician reviewed the orders with the surveyor. The physician confirmed there was no evidence to indicate he was contacted when the Resident's BS was over 350. The physician said, He (indicating the Resident) had a long acting [MED] also so I would not have changed any orders had I known. At 8:30 AM on [DATE], the above issues were presented to the administrator. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
506,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,690,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident received the appropriate treatment for [REDACTED]. In addition, this placed the resident at risk for developing antibiotic-resistance. Resident identifier: #57. Facility census: 100. Findings included: a) Resident #57 Record review on 01/29/20, revealed on 12/31/19 the physician ordered a urinalysis with culture and sensitivity (UA/C&S). The C&S culture results were received by the facility on 01/04/20 with Escherichia coli (E coli) cultured at a colony count greater than 100,000. The physician was contacted with the results and [MEDICATION NAME] milligrams (mg) two (2) times a day for 10 (ten) days. A review of the Medication Administration Record [REDACTED]. Review of the C&S report found [MEDICATION NAME] (Cipro) is Resistant (R) to E coli and not an effective antibiotic to treat this organism. In an interview with the facility Medical Director (MD) on 01/29/20 at 4:10 PM. The MD reported he would not have [MEDICATION NAME] Resident #57 if he had been told it was resistant. On 01/29/20 at 2:10 PM, the Director of Nursing (DON) confirmed Resident #57 had received the wrong antibiotic. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
507,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,693,E,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure water flushes, for a resident with a feeding tube, were provided as directed by the physician. This was true for one (1) of two (2) residents reviewed for the care area of feeding tube. Resident identifier: #98. Facility Census: 100. Findings included: a) Resident #98 Review of Resident #98's, record found she was admitted to the facility on [DATE]. Record review also revealed, the resident was to have nothing by mouth (NPO) and received all of her nutrition and fluids through the feeding tube due to a prior [MEDICAL CONDITIONS]. Physician order [REDACTED]. --10/07/19 through 10/11/19- Water flushes via the tube feeding- 90 cubic centimeters (cc) every six (6) hours-12 am- 6 am- 12 pm- 6 pm. --10/12/19 through current - Water flushes via the tube feeding- 1[AGE] cc every four (4) hours-12 am- 4 am- 8 am- 11 am- 5 pm and 8pm. Review of Resident #98's Medication Administration Record [REDACTED] --10/07/19 at 6 pm. --10/11/19 at 4 pm. --10/14/19 at 4 pm. --10/16/19 at 4 pm. --10/23/19 at 12 pm. --11/01/19 at 8 am. --11/04/19 at 8 am. --11/25/19 at 8 am. --[DATE] at 4 pm. --12/04/19 at 8 am. --12/06/19 at 11 am. --12/09/19 at 5 pm. --12/13/19 at 5 pm. --[DATE] at 5 pm. --12/22/19 at 8 am. --12/24/19 at 8 am and 11 am. --[DATE] at 11 am. --12/29/19 at 8 am and 11 am. --01/03/20 at 8 am and 11 am. --01/06/20 at 11 am. --0[DATE] at 11 am and 5 pm. --01/13/20 at 5 pm. --[DATE] at 5 pm. --01/20/20 at 11 am and 5 pm. --01/24/20 at 11 am. On 02/03/20 at 1:15 pm, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) verified, after review of the medical records for Resident #98, the water flushes as mentioned above had not been given due to [MEDICAL TREATMENT] treatments. The physician/registered dietician had not been notified to arrange water flushes to accommodate her [MEDICAL TREATMENT] treatments to ensure the proper hydration was maintained. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
508,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,697,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to manage the resident's pain in accordance with facility policy and physician order. This was true for one (1) of three (3) of residents reviewed for the care area of pain. Resident identifier: #17. Facility census: 100. Findings included: a) Policy Review According to the facility's policy entitled, Medication Administration - general guidelines with effective date 1/1/17 When PRN medications are administered, the following documentation is provided: .Complaints or symptoms for which the medication was given, including any nonpharmacologic interventions attempted by the nursing staff prior to administration of the PRN medication. b) Resident #17 Review of Resident #17's physician's orders [REDACTED]. Resident #17 also had an order initiated 03/01/19 to evaluate for signs and symptoms of pain every four (4) hours. This pain assessment was performed daily at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. From January 1, 2020, through January 14, 2020, Resident #17's pain was assessed as 0 on a scale from 1-10. A score of 0 indicates the absence of pain. On 01/13/20 Resident #17's [MED] with [MEDICATION NAME] order was changed from a scheduled order three times per day to one tablet by mouth every six hours as needed for pain. For this medication, the MAR indicated [REDACTED]. On 01/14/20, Resident #17's pain assessment order was changed to evaluate for signs and symptoms of pain every six (6) hours. This pain assessment was performed daily at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. Resident #17's pain was assessed as 0 on a scale from 1-10 at each assessment from 01/14/20 through 01/28/20. On 01/14/20 at 6:55 PM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was assessed as level 6, on a scale from 1-10. The medication was documented as effective. On [DATE] at 8:07 PM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was reported as level 4, on a scale from 1-10. The medication was documented as effective. On 01/20/20 at 7:39 PM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was reported as level 5, on a scale from 1-10. The medication was documented as effective. On 01/21/20 at 9:04 AM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was reported as level 5, on a scale from 1-10. The medication was documented as effective. On 01/22/20 at 8:02 PM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was reported as level 4, on a scale from 1-10. The medication was documented as effective. On 0[DATE] at 8:31 PM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was assessed as level 0, on a scale from 1-10. The medication was documented as effective. On 01/24/20, Resident's [MED] with [MEDICATION NAME] order was changed to one (1) tablet by mouth every six (6) hours as needed for pain, administer after repositioning for pain is ineffective. For this medication, the MAR indicated [REDACTED]. On 01/25/20 at 10:30 AM, Resident #17 received [MED] with [MEDICATION NAME]. The resident's pain level was not assessed prior to the medication administration. The medication was documented as effective. On 01/26/20 at 9:50 AM, Resident #17 received [MED] with [MEDICATION NAME]. The resident's pain level was not assessed prior to the medication administration. The medication was documented as effective. On 0[DATE] at 9:01 PM, Resident #17 received [MED] with [MEDICATION NAME]. The resident's pain level was not assessed prior to the medication administration. The medication was documented as effective. During an interview on 01/29/20 at 10:21 AM, the Director of Nursing (DON) confirmed Resident #17's pain was not assessed prior to receiving as needed pain medication on 01/25/20, 01/26/20, and 0[DATE]. The DON acknowledged the resident's every six (6) hour pain assessments documented no pain and were performed at 12:00 AM, 6:00 AM, 12:00 PM. and 6:00 PM, and not when the as needed pain medication was administered. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
509,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,698,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident received Phosphorus supplements as requested. This failed practice had the potential to affect a limited numer of residents. Resident identifier: #98. Facility census: 100. Findings included: a) Resident #98 Review of Resident #98's medical record found on [DATE] at 10:23 AM, the [MEDICAL TREATMENT] center physician requested a phosphorus supplement due to the resident's phosphorus level being low at 2. The facility Nurse Practitioner (NP) was notified on [DATE] at 2:17 PM, and said, The nephrologist needs to recommend what phosphorus supplement he wants. On 01/02/20 at 12:16 pm, the [MEDICAL TREATMENT] center was notified concerning what phosphorus supplement the nephrologist wanted. The [MEDICAL TREATMENT] center responded with, (Nephrologist Name) is out of town and will not return till 01/13/20. The Resident's medical record contained no documentation the attending physician was consulted for a phosphorus supplement. In addition, no further communication between the [MEDICAL TREATMENT] center and the facility concerning the phosphorus could be found. During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 02/03/20 at 1:30 pm, they confirmed there was no documentation to indicate the attending physician was notified concerning a phosphorus supplement. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
510,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,726,F,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assure nursing staff possess the competencies and skills sets to recognize proper antibiotic use to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifer: #57. Facility census: 100. Findings included: a) Resident #57 Review of Resident #57's medical records found on 12/31/19, the physician ordered a urinalysis with culture and sensitivity (UA/C&S.) The urinalysis result could not be found in the medical record. On 01/04/20 the facility received the results of the C&S. The Registered Nurse (RN) called the physician to report the results. The registered nurse obtained a verbal order from the physician for the [MEDICATION NAME] milligrams (mg) , two times a day for ten (10) days for greater than 100,000 colony count of the organism Escherichia coli (E. coli.). However, the C&S noted the organism was resistant to [MEDICATION NAME]. ([MEDICATION NAME] is the same as Cipro.) There is no indication the registered nurse reported to the physician that the organism was resistant to [MEDICATION NAME] (Cipro). The C&S report was never signed by the physician to indicate he had reviewed the report. The facility continued to administer this antibiotic for 10 days as ordered. As a result, the resident received an antibiotic that was not appropriate to treat her urinary tract infection. She continued to have signs and symptoms of urinary tract infection, specifically burning upon urination and foul-smelling urine. On 01/29/20, after surveyor intervention, the physician ordered another UA/C&S to be obtained. The physician also ordered the antibiotic [MEDICATION NAME] ([MEDICATION NAME]) intravenously for ten (10) days. The urinalysis obtained on 01/29/20 showed 2+ (large amount) of bacteria. The C&S is pending. On 01/29/20 the Director Of Nursing confirmed the Resident received the wrong antibiotic. At 9:30 AM on 1/30/20, the facility confirmed they did not implement an antibiotic use protocol which included reporting laboratory results to the facility physician. On 01/30/20, the Clinical Care Supervisor (CCS) stated she contacted the laboratory. The CCS stated no UA had been performed by the laboratory on 12/31/19, although it had been ordered. There is no indication the facility had called the laboratory to obtain the UA results prior to surveyor intervention. As a result, the facility did not discover the UA had not been performed as ordered. Prior to surveyor intervention, the physician and facility staff, including the infection preventionist, did not identify or attempt to correct this failed practice. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
511,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,758,E,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident's [MEDICAL CONDITION] medication regimen was managed and monitored to promote or maintain the resident's highest level of mental, physical, and psychosocial well-being for four (4) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifiers: #40, #38, #98, #57. Facility census: 100. Findings included: a) Resident (R) #40 Record review indicated the facility's physician did not appropriately respond to the Gradual Dose Reduction (GDR) for [MEDICATION NAME] ([MEDICAL CONDITION] medication, selective serotonin reuptake inhibitor used to treat anxiety and depression) recommended by the pharmacist on the on the Medication Regimen Review (MRR) for 01/16/2020. The MRR completed on 01/16/2020 by the pharmacist noted the last GDR evaluation for [MEDICATION NAME] was on 0[DATE] was contraindicated by the physician. The last dose adjustment was on 12/09/19 at which time the physician increased the [MEDICATION NAME] dose from 10mg to 15mg at bedtime (HS). The pharmacist indicated, Residents [MEDICATION NAME] 15 mg HS is due for GDR evaluation which must be attempted unless clinically contraindicated. The physician signed the MRR on 1/20/20 and left the form blank without providing any further comments to indicate his response to the GDR, or any further action to be taken. Review of the Resident's Mediation Administration Record on 02/03/2020 at 10:00 AM, revealed R #40 had been receiving [MEDICATION NAME] 15mg at bedtime for major [MEDICAL CONDITION] since [DATE] through current with no decrease in dose. On 01/29/20 at 12:25 PM, during an interview Regional Director of Operations #129 reviewed and verified the GDR recommendation dated 01/16/2020 was not appropriately acknowledged or completed by the physician. During an interview on 01/29/2020 at 12:35 PM, the Director of Nursing (DON) reviewed the GDR on the MRR dated 01/16/2020, and agreed the physician did not appropriately respond, and the GDR was incomplete. The DON stated, How could you know what he (physician) wanted done? He never filed the comment section or any of the check boxes to say if he agreed or disagreed. This should have been caught. The DON further explained, The facility's new procedure for processing MRR with GDR recommendation is for the pharmacy to review Resident's Medication Regimen, do their recommendations, then the provider addresses the recommendations, and then it is passed down to the Clinical Care Supervisor to ensure the orders are put through. The DON verified nursing staff have not been signing off on the actual MRR/ GDR paperwork, they (nursing) only enter the order and their name will appear on that specific order in the electronic medical record. b) Resident #38 Review of the Resident's medical record found the Resident is receiving [MEDICATION NAME] 0.5 milligrams (mg's), give 1 tablet by mouth, two times a day (BID) related to unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition. Review of the nursing notes, dated 05/07/19, found an entry, (Name of physician) in facility; new orders to increase [MEDICATION NAME] to 0.5 mg. BID; [MEDICATION NAME] cream to face [MEDICAL CONDITION] QS. (Quantum satis (abbreviation q.s. or Q.S.) is a Latin term meaning the amount which is enough. It has its origins as a quantity specification in medicine and pharmacology, where a similar term quantum sufficit (as much as is sufficient) has been used (abbreviated Q.S.) Review of the facility's psychopharmacological medication monitoring logs for May 2019 continuing to January 2020 found the order: Monitor effectiveness of antipsychotic medication ([MEDICATION NAME]) as evidence by patient is free of behaviors, delusions, every day and night shift. The specific behaviors for which the antipsychotic medication, [MEDICATION NAME], was administered was not specified. The daily documentation on the MAR indicated [REDACTED]. Review of the current care plan, revised on 08/03/19, found the problem: (Name of Resident) received antipsychotic medications ([MEDICATION NAME]) related to behavior management as evidenced by wandering, attempting to provide care to other residents. On 01/29/20 at 12:33 PM, the Director of Nursing (DON) was asked to provide evidence the Resident had an increase in behaviors at the time of the increase in [MEDICATION NAME]. The DON said the resident was scratching her face at the time of the increase in medication. The DON said, We were monitoring that as a condition rather than a behavior. On 02/03/20 at 4:00 PM, the Resident's physician was interviewed regarding the increase in [MEDICATION NAME]. The physician reviewed his progress notes scanned into the medical record at the time of the increase. The physician verified no notes, written by himself, were scanned in the electronic medical record on or around 05/08/19. He said he must have written a note regarding the increase in [MEDICATION NAME] but the facility did not scan in his notes. The physician stated, Let me go see if I have any notes around that time. At approximately 4:45 PM on 02/03/20, the physician returned with a typed note for an acute visit dated 05/07/19. This progress note said the patient was scratching, picking at her face and neck, she was standing at the mirror with wash cloth scrubbing left side of her face when we walked into her room, she states, I'm just trying to get all the stuff off. The physician said the medication was increased due to daily self injurious behaviors of picking/scratching her face until she bleeds. On [DATE] at 8:02 AM, the above information was discussed with the Administrator. At the close of the survey on [DATE] at 12:30 PM, no further information was provided by the facility. d) Resident #57 A record review for Resident #57 on 01/29/20, revealed a Gradual Dose Reduction (GDR) dated 08/14/19, recommended decreasing [MEDICATION NAME] from 20 milligrams (mg) to 10 (mg). On 09/09/19 the facility Medical Director (MD) had agreed and signed to decrease [MEDICATION NAME] to 10mg. [MEDICATION NAME] was decreased to 10 mg on 09/30/19. In an interview with the Director of Nursing (DON) on 01/29/20 01:12 PM, verified the order to decrease Celaxa was not completed in a timely manner. c) Resident #98 Review of Resident #98's medication regimen found the resident is currently receiving [MEDICATION NAME] 25 milligrams (mg) three times daily, effective date was [DATE]. Further review found the resident's [MEDICATION NAME] was increased from 25 mg twice daily to three times daily on [DATE]. There was no documented behaviors to indicate the need to increase the medication. Since the increase, the resident continues to have no behaviors to indicate the continued use of the medication. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 02/03/20 at 12:30 pm, confirmed there was no documented behaviors for Resident #98 to indicate the increase of [MEDICATION NAME]. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
512,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,761,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medications were stored and labeled in accordance with facility policay for one (1) of eight (8) [MED]'s stored in the B-hallway medication cart. Resident identifier: #[AGE]. Facility census: 100. Findings included: a) Policy Review The facility's policy entitled, Vials and [MEDICATION NAME] of Injectable Medications with effective date 01/01/2017 stated, When a vial is opened, the licensed nurse records the opened date on the vial. b) Resident #[AGE] On 01/28/20 at 9:08 AM, the B-hall medication cart was inspected with Licensed Practical Nurse (LPN) #[AGE] in attendance. Resident #[AGE]'s [MEDICATION NAME] Solution Pen-injector ([MED] [MEDICATION NAME]) was not dated when opened. LPN #[AGE] confirmed Resident #[AGE]'s [MED] pen-injector was not dated when opened. The facility's Administrator was informed of the above findings on 01/28/20 at 9:34 AM. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
513,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,773,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to promptly notify the ordering physician of laboratory results outside of the clinical reference range for Resident #98. Additionally, the facility failed to obtain laboratory testing for Resident #57, as directed per physician's orders [REDACTED]. Resident identifiers: #98 and #57. Facility census: 100. Findings included: a) Resident #98 Review of Resident #98's medical records found an order to obtain an ammonia level. This level was obtained on [DATE] at 3:31 pm. The ammonia level was [AGE] which was critically high. Normal ammonia level is 9-35. Review of the progress notes found the attending physician was not notified of the labortory results until 10/21/19 at 5:11 pm. An interview with the Director of Nursing, on 01/30/20 at 1:10 pm, confirmed, after the review of Resident #98's medical record, there was a delay in notifying the physician of a critical lab. b) Resident #57 Record review on 01/29/20, revealed on 12/31/19 the physician had ordered a urinalysis with culture and sensitivity (UA/C&S). The C&S culture results were received by the facility on 01/04/20 with Escherichia coli (E coli) cultured at a colony count greater than 100.000. The physician was contacted with the results and [MEDICATION NAME] milligrams (mg) two (2) times a day for 10 (ten) days. Review of the Medication Administration Record [REDACTED]. Review of the C& S, [MEDICATION NAME] (Cipro) is Resistant (R) to E coli an not an effective antibiotic to treat this organism. In an interview with the facility Medical Director (MD) on 01/29/20 at 4:10 PM. The MD reported he would not have [MEDICATION NAME] Resident #57 if he had been told it was resistant. On 01/29/20 at 2:10 PM the Director of Nursing (DON) confirmed Resident #57 had received the wrong antibiotic. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
514,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,812,F,0,1,CN2N11,"Based on observation and interview, the facility failed to store, prepare, distribute and serve food in a manner to protect for food service safety. During the kitchen tour it was discovered the floor of the reach-in refrigerator had food particles and cardboard stuck to the floor. This had the potential to affect any residents receiving nourishment from the kitchen. Facility census: 100. Findings included: a) Kitchen tour During the kitchen tour on 0[DATE] at 11:24 AM, it was discovered the reach-in refrigerator to be unclean, with food particles and cardboard stuck to the floor. This failed practice provided for unsanitary storage for refrigerated foods. In an interview on 0[DATE] at 11:24 AM with the Dietary Manager (DM), she verified the refrigerator was dirty and needed to be cleaned. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
515,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,868,F,0,1,CN2N11,"Based on record review and interview, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee consisted of the required members. The medical director (MD) or his/her designee did not attend quarterly QAA meetings. This had the potential to affect all residents. Facility census: 100. Findings included: a) QAA Review of the signatures on the attendance sheets for QAA meetings found the medical director only attended 2 quarterly QAA meetings from January 2019 - January 2020. The MD attended meetings held on 10/24/19 and a meeting dated July 2019. The actual date of the meeting was not included on the signature sheet. On [DATE] at 8:07 AM, the Administrator confirmed signature sheets showed the MD only attended 2 quarterly QAA meetings for the year. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
516,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,880,F,0,1,CN2N11,"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. This failed practice had the potential to affect more than an isolated number of residents. Facility census: 100. Findings included: a) B-hallway medication room On 01/28/20 at 9:08 AM, the B-hallway medication room was inspected with Licensed Practical Nurse (LPN) #[AGE] in attendance. Under the sink were stored two (2) cartons with six (6) cups of applesauce in each carton. LPN #[AGE] removed the applesauce from under the sink. On 01/28/20 at 9:34 AM, the facility's Administrator was informed that applesauce was stored in an unsanitary area under the medication room sink. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
517,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,881,K,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to implement an antibiotic use protocol, including reporting laboratory results to the facility physician. This resulted in the failure to ensure Resident #57 received appropriate treatment for [REDACTED].) In addition, this placed the resident at risk for developing antibiotic-resistance. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Prior to surveyor intervention, the physician and facility staff, including the infection preventionist, did not identify or attempt to correct this failed practice. Due to the facility's failure to implement an antibiotic stewardship protocol the State Agency (SA) determined there was an immediate jeopardy (IJ) present for more than a limited number of residents residing in the facility. The likelihood of serious harm due to this IJ situation exists because the facility failed to recognize the resident was treated with an inappropriate antibiotic. Being treated with an antibiotic resistant to the organism identified could have resulted in the resident being septic. Due to the system failure to recognize the use of the incorrect antibiotic to treat in antibiotic resistant organism, all residents were potentially at risk for the incorrect antibiotic be prescribed with the negative outcome [MEDICAL CONDITION] being present as well. The following details the timeline of the IJ situation. --The IJ started on 01/04/20. --The facility Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy (IJ) at 12:22 PM on 01/30/20. --The facility submitted their first abatement Plan of Correction (POC) at 1:55 PM on 01/30/20. --The SA requested changes to the abatement POC. --At 2:08 PM and a second abatement POC was submitted by the facility on 01/30/20. --This POC was accepted by the SA at 2:10 PM on 01/30/20. --The IJ was abated at 11:40 AM on 02/03/20 when the SA observed Resident #57's urine culture and sensitivity was received and appropriate antibiotic was ordered by facility's physician/staff. The facility's abatement plan of correction consisted of the following: 1. Resident # 57 was identified as being affected by the alleged deficient practice of failing to implement an antibiotic use protocol, including reporting laboratory results to the facility physician. This resulted in the failure to ensure Resident #57 received appropriate treatment for [REDACTED].#57 physician was notified immediately by the Director of Nurses (DON) on 1/29/2020. Resident #57 physician current course of treatment implemented was to obtain a UA with C & S this was completed on 1/29/2020 by the Unit Charge Nurse (UCN). The Unit Charge Nurse obtained an order for [REDACTED]. Quality Standards Nursing Coordinator educated the Director of Nurses (DON), Clinical Care Supervisor (CCS), and Registered Nursing Assessment Coordinator (RNAC) on antibiotic stewardship data base, documentation expectations, and follow through immediately on 1/30/2020. All Unit Charge Nurses on duty will be educated immediately by a Quality Standards Nursing Coordinator on 1/30/2020 on reading/interrupting a UA with C & S lab results, documentation expectations, communication with physician on lab results, and follow through. Nurse Practitioner examined Resident #57 and reviewed findings with physician in person on 1/30/2020. The CCS or designee will obtain C & S results from the lab by 2/3/2020. The CCS or designee will immediately upon receipt of lab results will report to physician or nurse practitioner for further orders as necessary. 2. DON or designee will educate all nurses at the being of each shift prior to going to the floor until all nurses have been educated starting 1/30/2020 - 2/3/2020. Any nurse on leave of absence will be educated immediately upon return to work prior to going to the floor to provide care. Quality Standards Nursing Coordinator completed an audit of current antibiotic use on 1/29/2020 and no other residents were identified as being affected by the alleged deficient practice. The nurse receiving lab results will review results with the physician or nurse practitioner by the end of the shift. The UCN will document physician or nurse practitioner notification and their response by the end of the shift. The UCN must contact the physician or nurse practitioner and obtain new orders within accordance with antibiotic stewardship. The UCN will document physician or nurse practitioner notification and their response by the end of the shift. The CCS or designee will monitor antibiotic stewardship to ensure diagnostic results have been obtained and the physician or nurse practitioner was made aware and required documentation is completed daily. Antibiotic Stewardship data base will be reviewed daily by the CCS or RNAC or designee daily. 3. The DON will review all findings and report in QAA monthly for follow up to assure POC is effective. Resident identifier: #57. Facility census: 100. Findings included: a) Resident #57 Review of Resident #57's medical records found on 12/31/19, the physician ordered a urinalysis with culture and sensitivity (UA/C&S.) The urinalysis result could not be found in the medical record. On 01/04/20 the facility received the results of the C&S. The Registered Nurse (RN) called the physician to report the results. The registered nurse obtained a verbal order from the physician for the [MEDICATION NAME] milligrams (mg) , two times a day for ten (10) days for greater than 100,000 colony count of the organism Escherichia coli (E. coli.). However, the C&S noted the organism was resistant to [MEDICATION NAME]. ([MEDICATION NAME] is the same as Cipro.) There is no indication the registered nurse reported to the physician that the organism was resistant to [MEDICATION NAME] (Cipro). The C&S report was never signed by the physician to indicate he had reviewed the report. The facility continued to administer this antibiotic for 10 days as ordered. As a result, the resident received an antibiotic that was not appropriate to treat her urinary tract infection. She continued to have signs and symptoms of urinary tract infection, specifically burning upon urination and foul-smelling urine. On 01/29/20, after surveyor intervention, the physician ordered another UA/C&S to be obtained. The physician also ordered the antibiotic [MEDICATION NAME] ([MEDICATION NAME]) intravenously for ten (10) days. The urinalysis obtained on 01/29/20 showed 2+ (large amount) of bacteria. The C&S is pending. On 01/29/20 the Director Of Nursing confirmed the Resident received the wrong antibiotic. At 9:30 AM on 1/30/20, the facility confirmed they did not implement an antibiotic use protocol which included reporting laboratory results to the facility physician. On 01/30/20, the Clinical Care Supervisor (CCS) stated she contacted the laboratory. The CCS stated no UA had been performed by the laboratory on 12/31/19, although it had been ordered. There is no indication the facility had called the laboratory to obtain the UA results prior to surveyor intervention. As a result, the facility did not discover the UA had not been performed as ordered. Prior to surveyor intervention, the physician and facility staff, including the infection preventionist, did not identify or attempt to correct this failed practice. The likelihood of serious harm due to this IJ situation exists because the facility failed to recognize the resident was treated with an inappropriate antibiotic. Being treated with an antibiotic resistant to the organism identified could have resulted in the resident being septic. Due to the system failure to recognize the use of the incorrect antibiotic to treat in antibiotic resistant organism, all residents were potentially at risk for the incorrect antibiotic be prescribed with the negative outcome [MEDICAL CONDITION] being present as well. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
525,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2017-11-10,241,D,0,1,FJSP11,"Based on observation and staff interview, the facility failed to provide a dining experience with dignity for one randomly observed resident, during a dinner time meal. One (1) nurse aid (NA) approached Resident #149 to set the resident up for the meal without speaking to the resident or letting the resident know what the NA was about to do. Resident identifier: #149 and #99. Facility census: 87. Findings include: a) Resident #149 Random observation during the dinner time meal, on 11/06/17 at 5:12 p.m., revealed Resident #149 was reclining in a geri chair beside a dinner table. Nurse Aide (NA) #44 came up behind Resident #149, and without saying anything to the resident or explaining what he was about to do changed the geri chair from a reclining position to a sitting position. The sudden quick movement from a reclining to a sitting position jarred the resident and caused the resident to scream out. b) Resident #99 Random observation during the dinner time meal, on 11/06/17 at 5:22 p.m., revealed NA #44 was feeding Resident #99 as she was leaning to the right side in her gerri-chair, with her head leaning forward. LPN #26 also in the dining room at the time and after observing NA #44 feeding Resident #99 agreed Resident #99 was not in good body alignment to promote feeding. LPN #26 proceeded to reposition the resident and prop the resident with folded blankets, after surveyor intervention, and instruct NA #44 on proper body alignment to promote feeding.",2020-09-01
526,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2017-11-10,279,D,0,1,FJSP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a care plan had measurable and/or individualized objectives for a resident on anti-anxiety medication. This was evident for one (1) of five (5) residents reviewed for unnecessary medications, out of fifteen (15) Stage II sampled residents. Resident identifier: #88. Facility census: 87. Findings include: a) Resident #88 The medical record was reviewed on 11/09/17. Physician orders [REDACTED]. at bedtime daily for anxiety. Review of the care plan found it lacked individualized, measurable goals for the use of anti--anxiety medications. The care plan did not identify the behaviors the facility intended to treat with the anti-anxiety medication. The care plan did not include measurable goals set for the resident's emotional and/or behavioral condition. Rather, the care plan focus stated (name of resident) receives anti-anxiety medications ([MEDICATION NAME]) r/t (related to) anxiety disorder. The goals stated Patient will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Their only non-pharmacological interventions were to encourage him to vent his feelings, and listen to his concerns. On 11/09/17 at 9:58 a.m. an interview was conducted with the director of nursing (DON). She said this resident does have targeted behaviors, but they were not listed on the care plan. She acknowledged that there was no focus on the behaviors that caused him to need the [MEDICATION NAME]. She acknowledged that there were no individualized or measurable goals for any targeted behaviors they were treating. She said she would correct these issues right away.",2020-09-01
527,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2017-11-10,371,E,0,1,FJSP11,"Based on observation and staff interview, the facility failed to maintain kitchen equipment in a sanitary manner. This practice has the potential to affect more than limited number Residents. Staff Identifiers: #66. Facility Census: 87. Findings include: On 11/06/17 at 2:40 p.m., inspection of the kitchen with the dietary assistant #66, revealed an observation of the food lid to hot bar was dirty. The dietary assistant #66 agreed the food lid to hot bar was dirty and should not have been.",2020-09-01
528,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2017-11-10,431,D,0,1,FJSP11,"Based on observation and staff interview the facility failed to store and label medications. Resident: #48, #81 and #88. 11/08/2017 11:05:14 AM in medication room B and 2 medication carts, LPN #72 Levemir multi vail use wasn't labeled with opened date on vial for Resident #48, LPN #56 11/08/2017 11:15:31 AM Medication Room A and 2 medication carts, LPN #23 pens LPN #4 Humalog pen not labeled with opened date, Resident #81 Novolog pen not labeled with opened date, Resident #88 Based on observations and staff interview, the facility failed to collaborate with the pharmacist, to ensure safety and effective use of medications. An opened and partially used insulin vial was not dated when initially opened. This had the potential to negatively impact the safety and/or potency of the medication. This was evident for three (3) of thirty one (31) opened insulin vials and pens stored in two (2) of four (4) carts. Resident identifiers: #48, #81, #80. Findings include: a) Resident # 48 Observation on 11/08/2017 at 11:05 a.m., found a Levermir vial which belonged to resident # 48 was opened and partially used. There was no date indicating when the vial was intially opened, or the date it should be discarded. The Licensed Practical Nurse (LPN) #72 agreed the date that it was opened should have been on the vial. b) Resident #81 and #80 Observation on 11/08/2017 at 11:15 a.m. found a Humalog pen which belong to Resident # 81 was opened and partially used. There was no date indicating when the pen was was intially opened, or the date to discard. A novolog pen belonging to Resident #80 was opened and partially used. There was no date indicating when the pen was intially opened, or the date to discard. The LPN # 4 agreed that it should have been labeled when it was intially opened. There was a place on the pens to put the opened dates that were blank. Interveiw with the Director of Nursing was completed on 11/09/2017 at 10:30 a.m. she was aware of the findings of the insulin not being dated of when the medication was intially opened and/or to be discarded. She stated the policy required it to be labeled when it is first used with the discard date. The DON says that she has a plan to fix this problem.",2020-09-01
529,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,574,E,0,1,J9FW11,"Based on observation, staff interview and information from the resident council meeting, the facility failed to provide information on how to contact the local ombudsman. This had the potential to affect more than an isolated number of residents. Facility census: 97. Findings include: a) Resident council meeting During the resident council meeting on 11/28/18 at 10:27 AM, the residents in attendance did not know how to contact the ombudsman if they would choose to do so. The facility's Social Worker (SW) #28, was also in attendance at the council meeting. SW #28 told the resident's the name and contact information of the local ombudsman was posted at the nurses station. After the meeting was adjourned, at 10:52 AM on 11/28/18, the SW and the surveyor reviewed the information posted at the nurses station. The name and contact information of the local ombudsman was not available. On 11/28/18 at 03:03 PM, the administrator said the contact information of the local ombudsman, Was posted but someone removed it, we have put it back.",2020-09-01
530,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,583,D,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure Resident #245's medical record was kept confidential. Resident #245's medication orders were observed to be hanging on the magnetic bulletin board in the residents room. This was a random opportunity for discovery. Resident Identifier: #245. Facility Census: 97 Findings Include: a) Resident #245 Observation of Resident #245's room at 12:34 p.m. on 11/26/18 found her medication list placed on her magnetic bulletin board with a magnet. The list had been printed by the facility and it appeared Resident #245's daughter had placed it on the board with a hand written note which read, Mom's Medications, and No [MEDICATION NAME]. An additional observation with the Director of Nursing (DON) at 1:05 p.m. on 11/27/18, found the medication list was still on the magnetic bulletin board in Resident #245's room. The DON removed the list and indicated it looked like Resident #245's daughter had placed the list there and she would call and talk to them about it. She agreed the medication should not have been posted in the residents room.",2020-09-01
531,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,584,D,0,1,J9FW11,"Based on observation and staff interview the facility failed to ensure Resident #245's wheelchair was in good prepare. The wheelchair was missing an arm rest on one side and the other arm rest was loose. This was a random opportunity of discovery. Resident Identifier: #245. Facility Census: 97 Findings Include: a) Resident #245 An observation of Resident #245's wheelchair at 9:40 a.m. with the Director of Nursing (DON) found the arm rest on the left side of her wheelchair was missing and the residents right arm rest on her wheelchair was loose. The DON stated, I will have (name of Maintenance Director) to fix it right away.",2020-09-01
532,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,622,D,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to convey all required transfer information to the receiving hospital for one (1) of two (2) residents reviewed for the care area of hospitalization . Resident identifier: #43. Facility census: 97. Findings include: a) Resident #43 On 09/17/18 at 5:18 am, Resident #43 was transferred to the hospital due to chest discomfort, shortness of breath, and upper extremity [MEDICAL CONDITION]. The Acute Care Transfer form provided to the receiving hospital did not include information regarding usual mental status, ambulation status, skin condition at time of transfer, devices and special treatments. The Acute Care Transfer form contained sections to provide this information. However, the sections were blank. During an interview on11/27/18 at 12:20 PM, the Director of Nursing agreed the information had not been completed on Resident #43's Acute Care Transfer form dated 09/17/18.",2020-09-01
533,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,641,E,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview the facility failed to ensure the Minimum Data Sets (MDS)s accurately reflected the resident's status. This was true for six (6) of twenty-six (26) resident's MDSs reviewed during the Long Term Survey Process (LTCSP). Resident #96's MDS was inaccurate in the area of death in the facility. Resident #14 MDS was inaccurate in area of pressure ulcers. Resident #9's MDS was inaccurate in area of falls. Resident #95's MDS was inaccurate in the area of nutrition. Resident #62's MDS was inaccurate in the area of positioning/mobility. Resident #84's MDS was inaccurate in area of unnecessary medications. Resident identifiers: #96, #14, #9, #95, #62 and #84. Facility census 97. Findings include: a) Resident #96 Resident #96 was admitted to the facility on [DATE] from an acute care hospital due to multiple falls at home. Resident's [DIAGNOSES REDACTED]. Further review of nurse's notes found on [DATE] at 8:05 am, the resident was found unresponsive. Cardiopulmonary resuscitation was initiated due to resident's wishes to be Full Code. Resident #96 was transported to local hospital and expired at the hospital. Review of the MDS with an assessment reference date (ARD) of [DATE] was marked, Death in Facility. During the review of the attending physician's discharge summary found: Patient died at (Name of local hospital. Interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on [DATE] at 3:00 pm, confirmed the resident did not die in the facility and the MDS with ARD of [DATE] was inaccurately coded. They both agreed the MDS should have been coded, Discharge with assessment return not anticipated. b)Resident #14 Medical record review found a Wound Assessment-Pressure Ulcer Assessment, dated [DATE] read: Right and left buttocks, 9.6 centimeters (cm) in length, 9 cm in width and 0.1 cm in depth, stage II. Area less red and not as firm, now with three (3) open areas. Further review found a MDS with ARD of [DATE], was noted Resident #14 had two (2) Stage II pressure ulcers present. Interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on [DATE] at 1:00 pm, confirmed the resident did not die in the facility and the MDS with ARD of [DATE] was inaccurately coded. They both agreed the MDS should have been coded, Three (3) Stage II pressure ulcers . c) Resident #9 Resident #9's medical records indicated she experienced a fall from her bed on [DATE]. Resident #9 had a quarterly Minimum Data Set (MDS) completed with Assessment Reference Date (ARD) [DATE]. Resident #9 also had a MDS completed with ARD [DATE]. Section J, Health Conditions, indicated she had experienced no falls since the prior assessment. During an interview on [DATE] at 12:06 PM, Registered Nurse Assessment Coordinator (RNAC) #127 stated Resident #9's MDS with ARD [DATE], Section J, Health Conditions, should have indicated the resident experienced one (1) fall since the prior assessment. d) Resident #395 During an interview on [DATE] at 11:33 AM, Resident #395 stated she had lost weight recently and was concerned about the weight loss. She said she used to weigh 214 pounds and her weight had decreased to the 170s during her stay at the facility. Resident #395's weight records, Nutritional Risk Notes, and Minimum Data Set (MDS) assessments were reviewed. A quarterly MDS assessment with an Assessment Reference Date (ARD) of [DATE] was marked No or unknown for loss of five (5)% or more in the last month or loss of ten (10)% or more in the last six (6) months. When determining significant weight loss in section K of the MDS, the RAI manual instructs, Start with the resident's weight closest to 180 days ago and multiply it by .90 (or 90%). The resulting figure represents a 10% loss from the weight 180 days ago. If the resident's current weight is equal to or less than the resulting figure, the resident has lost 10% or more body weight. The current weight entered in Section K was 182 pounds. This weight (rounded per RAI manual instructions) was measured on [DATE], per Resident #395's weight records. The weight closest to 180 days preceding the [DATE] weight was measured on [DATE] and was 208 pounds (rounded per RAI manual instructions). A decrease from 208 pounds to 182 pounds indicated a significant weight loss over six (6) months, per guidance from the RAI manual. A Nutritional Risk Note written in Resident #395's electronic medical record by the facility's Dietary Services Supervisor (DSS) #122 with an effective date of [DATE] was marked for 10% or Greater Loss in 180 days. The weight used for the current weight in this note was the same as the current weight used on Section K of the MDS for the ARD of [DATE]. A discharge MDS assessment for Resident #395 with an ARD of [DATE] was marked No or unknown for loss of five (5)% or more in the last month or loss of ten (10)% or more in the last six (6) months. The current weight entered in Section K was 178 pounds. This weight was measured on [DATE], per Resident #395's weight records. The weight closest to 180 days preceding the [DATE] weight was measured on [DATE], per Resident #395's weight records and was 203 pounds (rounded per RAI manual instructions). A decrease from 203 pounds to 178 pounds indicated a significant weight loss over six (6) months, per guidance from the RAI manual. A Nutritional Risk Note written in Resident #395's electronic medical record by DSS #122 with an effective date of [DATE] was marked for 10% or Greater Loss in 180 days. The weight used for the current weight in this note was the same as the current weight used on the discharge MDS with an ARD of [DATE]. On [DATE] at 10:44 AM, DSS #122 was asked why she did not code either MDS assessment for significant weight loss over six (6) months when she had marked on her Nutritional Risk Notes that Resident #395 had 10% or Greater Loss using the same two (2) current weight values. She stated that the Nutritional Risk Notes did not correspond with the MDS assessments. She stated that although there was significant weight loss in a timeframe close to 180 days, she did not code this on the MDS because the current weight and comparison weight on each MDS were not exactly 180 days apart. She said she had received an email from The Centers for Medicare and Medicaid Services (CMS) telling her that the RAI Manual had changed and she was to code significant weight loss only if it occurred exactly 180 days preceding the current weight entered in Section K of the MDS. She did not locate or provide a copy of this email for review before the end of the survey. During a phone interview on [DATE] at 12:16 PM, Corporate Registered Dietitian (RD) #133 confirmed that company policy dictates that significant weight loss over a time period of 180 days could only be coded on the MDS if the weight loss occurred at exactly 180 days preceding the current weight marked on the MDS Section K. She added that the policy was developed because there was no clarification in the RAI manual of what the word closest meant in the instructions to use the weight closest to 180 days ago. On [DATE] at 4:04 PM, the definition of close was located in Merriam-Webster's online dictionary. The word close, an adjective, means having little space between items or units or being near in time, space, effect, or degree, according to the dictionary entry. On [DATE] at 10:42 AM, the facility's Director of Nursing was informed of the issue. No further information was provided by the facility prior to the end of the survey. e) Resident #62 Observation of the resident at 1:54 PM on [DATE] found the resident appeared to have limited use of her hands and shoulders. Review of the resident's most recent Minimum Data Set (MDS), a annual, with an assessment reference date (ARD) of [DATE], found the resident was coded as having no contractures and having full use of her right dominant side. At 8:45 AM on [DATE], the Registered Nurse Assessment Coordinator (RNAC) #47 said the MDS was incorrectly coded. RNAC #47 said the MDS should be coded as the resident has limitations of her dominant right side. f) Resident #84 On [DATE], the resident was seen by the nurse practioner (NP). The NP prescribed [MEDICATION NAME], an antidepressant, for a [DIAGNOSES REDACTED]. Review of the residents admission Minimum Data Set (MDS) was a Assessment Reference Date (ARD) of [DATE], found the MDS was not coded to reflect the residents [DIAGNOSES REDACTED]. At 3:42 PM on [DATE], the Registered Nurse Corporate Coordinator, [NAME] #135, confirmed the care plan was incorrectly coded.",2020-09-01
534,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,656,E,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to develop/and or implement care plans for 4 of 23 residents whose care plans were reviewed. Resident #44's care plan was not developed to include how the facility would provide care to a Dementia resident. Resident #45's care plan was not was implemented for Dementia care. Residents #6 and #70's care plans were not implemented to anchor catheters. Resident identifiers: #44, #45, #6, and #70. Facility census: 97. Findings include: a) Resident #44 Review of the current care plan, revised on 07/20/17, found the problem: (Name of Resident ) has impaired cognitive function related to Dementia. The goal associated with the problem was: Patient will maintain current level of cognitive function through the review date. Interventions included: Administer Meds ([MEDICATION NAME]) as ordered Document/report to physician any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Engage patient in simple, structured activities that avoid overly demanding tasks. A second care plan problem addressed the resident was receiving [MEDICATION NAME] for delusions and hallucinations. The goal of this care plan was: The resident will be/remain free of drug related complications including movement disorder. Interventions included: Administer medications as ordered and monitor for side effects. Encourage resident to vent feelings. Monitor/record/report to physician as needed side effects and adverse reactions From the guidance to surveyors: Residents living with dementia require specialized services and supports, (e.g., specialized activities, nutrition, and environmental modifications) that vary, based on the individual's abilities and challenges related to their condition. Dementia causes significant intellectual functioning impairments that interfere with life, including activities and relationships. People living with dementia may lose their ability to communicate, solve problems, and cope with stressors. They may also experience fear, confusion, sadness, and agitation. On 06/01/18, the resident's physician prescribed [MEDICATION NAME], an antipsychotic medication, .25 milligrams (mg's) two times a day (BID) for a [DIAGNOSES REDACTED]. The physician documented the reason for starting [MEDICATION NAME] as, Patient will not leave her room to attend activities stating, If I leave the bugs will come in my room and get in my bed, I have to keep the door shut to keep the bugs out, they sometimes knock on my window and try to get in. At 9:15 on 11/29/18, the care plan was discussed with the director of nursing (DON). The DON was unable to provide evidence the care plan addressed interventions as to how the staff were to provide care when the resident was delusional. The DON confirmed the care plan did not discuss what staff should do when the resident had delusions and hallucinations. The DON could not demonstrate how the care plan individualized this resident's dementia care needs. b) Resident #45 Record review found the resident was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED].>[MEDICAL CONDITION], Dementia, and Depression. On 09/12/18, the antipsychotic, [MEDICATION NAME] 25 mg., two times (BID) a day was added to the residents medication regime for behaviors. Review of the current care plan, updated on 04/25/18, found the following problems related to the resident's behaviors: (Name of Resident) is verbally abusive and physically aggressive behaviors toward staff while providing care related to ineffective coping skills. The goal was the patient will demonstrate effective coping skills, as evidenced by not being verbally abusive to staff while providing care through next review date. Interventions included: Analyze key times, places, circumstances, triggers and what de-escalates behavior and document. assess patients coping skills and support system. Anticipate patients needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. Assess patients understanding of the situation. Allow time for the patient to express self and feelings towards the situation. When patient becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation if response is aggressive staff to walk calmly away, and approach later. A second care plan problem, updated on 01/29/18 found: (Name of Resident) has a behavioral problem related to yelling for help instead of utilizing the call bell system for needs and assistance. Resident will hit at staff while providing care. The goal associated with the problem was: The resident will have fewer episodes of yelling for help instead of utilizing the call bell system for requesting her needs. Interventions included: Anticipate and meet patients needs to reduce behavioral symptoms. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take patient to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location time of day persons involved and situations. Document behaviors and potential causes. Report findings to attending physician and or update care plan as appropriate. Privately discuss inappropriate behaviors with patient and explain why his her behavior is unacceptable in the nursing facility. Document discussion. Report outcome to physician and or update care plan as appropriate. At 11/28/18 at 02:41 PM, the director of nursing confirmed she was unable to provide information to substantiate the above approaches were implemented as directed by the care plan. The DON confirmed the interventions were in place before the antipsychotic medication was started. The DON further confirmed the non-pharmacological interventions were not implemented before starting the antipsychotic medication. During an interview with the DON and administrator on 11/29/18 at 10:34 AM, the DON said, I have nothing else to give you. c) Resident #6 On 11/26/18 at 1:35 pm, an observation with Employee #52, Clinical Care Supervisor (CCS) found Resident #6 had an indwelling Foley Catheter. The catheter was not anchored to the resident's leg. Care Plan from electronic chart reviewed: Focus: Resident #6 has an Indwelling Catheter due to a pressure ulcer on coccyx, 20 FR with 10 cc balloon. Goal: Patient will be/remain free from catheter-related trauma through review date. Intervention: 1. Change catheter every 4 weeks and as needed. 2. Document pain/discomfort/intolerance due to catheter and report to physician as necessary. 3. Document/report to physician s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Provide patient-specific catheter care as ordered 4. URINARY CATHETER: Patient has a Foley. Position drainage bag and tubing below the level of the bladder to allow free flow of urine into the bag. Secure tubing. Cover drainage bag with appropriate privacy bag. Report any concerns to the Unit Charge Nurse. Provide catheter care and record volume of urine every shift. An interview on 11/27/18 at 10:00 am with the DON, the DON was informed of findings. No further information provided. e) Resident #70 On 11/28/18 at 9:23 AM, Indwelling Foley Catheter care observation with Nursing Assistant (NA) #40, it was noted the catheter anchor (used to prevent injury and accidental removal) was not on the resident's leg. Both NA #40 and NA #85 agreed that the anchor was not there and should be on the leg. During an interview on 11/28/18 at 10:04 AM, DoN was notified of findings that were observed. She stated that she was disappointed. The Facility Policy, Catheter Care, Urinary Dated; 8/2002. reads: -Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note; Catheter tubing should be strapped to the resident's inner thigh.) Care Plan from electronic chart: Resident #70 has an Indwelling Catheter for [MEDICAL CONDITION] bladder, 16 FR with 10cc balloon. - Patient will be/remain free from catheter-related trauma through review date. Change catheter every 4 weeks and as needed. Document pain/discomfort/intolerance due to catheter and report to physician as necessary. Document/report to physician s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Provide patient-specific catheter care as ordered URINARY CATHETER: Patient has a Foley. Position drainage bag and tubing below the level of the bladder to allow free flow of urine into the bag. Secure tubing. Cover drainage bag with appropriate privacy bag. Report any concerns to the Unit Charge Nurse. Provide catheter care and record volume of urine every shift.",2020-09-01
535,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,657,D,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to revise care plans when residents had changes in their care related to advance directives, position and mobility, and [MEDICAL TREATMENT] schedule. This was found to be true for three (3) of 23 sampled residents reviewed during the Long-Term Care Survey Process. Resident identifiers: #395, #62, #16. Facility census: 97. Findings included: a) Resident #395 On [DATE] at 1:32 PM it was noted through the screening portion of the Long-Term Care Survey Process that the code status marked on Resident #395's profile in the electronic medical record did not match the code status indicated on the care plan. The code status on the profile in the electronic medical record stated, Resuscitate (CPR); Feeding Tube Long-Term; Patient has a completed POST form dated: [DATE]; Limited Additional Interventions; IV Fluids for a trial period of no longer than: ,[DATE] days. A review of the current Physician order [REDACTED].#395's representative on [DATE], stated to Attempt Resuscitation/CPR and to provide Limited Additional Interventions, IV fluids for a trial period of no longer than ,[DATE]d(ays), and Feeding tube long-term. A previous POST form, signed by Resident #395's representative on [DATE], indicated to provide full interventions as well as IV fluids for a trial period of no longer than ,[DATE]d(ays). It was marked VOID. Resident #395's physician orders [REDACTED]. However, the advance directives documented on the care plan stated, Full interventions, IV fluids for a trial period of no longer than ,[DATE] days, Feeding tube long term. According to date stamps on the care plan, this information was last revised on [DATE] by Registered Nurse Assessment Coordinator (RNAC) #47. During an interview on [DATE] at 2:20 PM, RNAC #47 acknowledged that the advance directive information on the POST form and the care plan did not match and stated she would fix the problem immediately. On [DATE] at 10:42 AM, the facility's Director of Nursing (DoN) was informed of the issue. No further information was provided by the facility prior to the end of the survey. b) Resident #62 Review of the resident current care plan, revised on [DATE], found the following problem: (Name of Resident) has an ADL (activities of daily living) self care performance deficit related to altered mental status,[MEDICAL CONDITION], dementia, [MEDICAL CONDITIONS], contracture to left arm and hand and [MEDICAL CONDITION]. Review of the most recent minimum data set (MDS) an annual, with an assessment reference date (ARD) of [DATE], found the resident was coded as having no contractures. At 8:45 AM on [DATE], the Registered Nurse Assessment Coordinator (RNAC) #47, said the care plan was incorrect. The RNAC noted the resident had contractures when she was admitted to the facility on [DATE]. When the contractures resolved the care plan was never updated to reflect the resident currently has no contractures to the left arm and hand. c) Resident #16 A reviewed of Resident #16's medical record at 9:26 a.m. on [DATE] found the following physician order [REDACTED]. A review of Resident #16's care plan found the following focus statement, : [MEDICAL TREATMENT] related to [MEDICAL CONDITION]. This focus statement was added to the care plan on [DATE]. The goal associated with this focus statement read, : Will have no signs or symptoms complications fro [MEDICAL TREATMENT] through the review date. The revision date for this goal was [DATE] with a target date of [DATE]. The goals associated with this focus statement and goal included, Encourage patient to go for the scheduled [MEDICAL TREATMENT] appointments. Patient receives [MEDICAL TREATMENT] Tuesdays, Thursdays, and Saturdays at 6:15 a.m. at (Name of local [MEDICAL TREATMENT] center) . This intervention was added to the care plan on [DATE]. An interview with Registered Nurse Assessment Coordinator (RNAC) #47, at 9:56 a.m. on [DATE] confirmed Resident #16's care plan was not revised when her [MEDICAL TREATMENT] days and times changed on [DATE] at it should have been.",2020-09-01
536,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,660,D,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a plan was in place to address the the residents expressed desire to talk to someone about in-home and community agencies available before her discharge to home. This was true for one (1) resident reviewed for the care area of discharge to the community. Resident identifier: #95. Facility census: 97. Findings include: a) Resident #95 Record review at 9:20 AM on 11/27/18, found the resident was admitted to the facility on [DATE]. The resident was discharged to her home on 08/31/18. Review of the minimum data set (MDS), a 5 day Medicare Part A Stay, with an assessment reference date (ARD) of 06/19/18, found the resident participated in completing the MDS. The resident expected to be discharged to the community. When asked the question on the MDS, Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? The residents response was, yes. The Resident Assessment Instrument (RAI) manual provides the following direction when answering yes to the above question on the MDS: The goal of follow-up action is to initiate and maintain collaboration between the nursing home and the local contact agency to support the resident's expressed interest in talking to someone about the possibility of leaving the facility and returning to live and receive services in the community. This includes the nursing home supporting the resident in achieving his or her highest level of functioning and the local contact agency providing informed choices for community living and assisting the resident in transitioning to community living if it is the resident's desire. The underlying intention of the return to the community item is to insure that all individuals have the opportunity to learn about home and community based services and have an opportunity to receive long term services and supports in the least restrictive setting. CMS (Centers for Medicare and Medicaid Services) has found that in many cases individuals requiring long term services, and/or their families, are unaware of community based services and supports that could adequately support individuals in community living situations. Local contact agencies (LCAs) are experts in available home and community-based service (HCBS) and can provide both the resident and the facility with valuable information. On 11/27/18 at 10:06 AM, the social worker (SW) #28 was asked for verification of information provided to the resident about all community based services and support systems. There were no notes in the electronic medical record from social services discussing discharge placement. SW #28 said referrals for medical equipment were made and the resident was referred to a Home Health agency before discharge. He was unable to provide any documentation a discussion was held with the resident to determine what other agencies were available in her community. Such as agencies who provide meals, chore services, transportation, and other in-home care and community based services that could be available. On 11/27/18 at 10:17 AM, the supervisor of therapy services, Employee #118, said the therapists recommended the equipment needed at home. We always refer residents to a Home Health agency upon discharge, for a safe transition to the community. [NAME] #118 said her department does not look at other agencies available in the community, That is Social Services. At 10:40 AM on 11/27/18, a visiting social worker, from another company facility, SW #134 said, We will get some training in place to address this.",2020-09-01
537,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,684,E,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, observation, resident interview, and the National Pressure Ulcer Advisory Panel's (NPUAP), the facility failed to provide quality treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. This was true for six (6) of twenty-three (23) residents reviewed. For Residents #37, #14, #345, and #9 had wounds not assess, monitor and treat wounds as indicated. Resident #43 did not have a follow appointment as directed by the discharging physician. Additionally, Resident #59's bowel and bladder incontinence was not accurately assessed. Resident identifiers: #37, #14, #345, #9, #43, and #59. Facility census: 97. Findings include: a) Resident #37 Medical record review found Resident #37 was admitted to the facility on [DATE]. Additionally, Resident #37 had a facility acquired pressure ulcer to the Matrix. Review of Resident #37 nursing assessment and wound assessments: Nursing assessments for 01/09/18, 04/10/18, and 04/10/18- No pressure ulcers noted. --10/02/18- Initial wound assessment dated [DATE]: coccyx- Stage II- measured 0.9 centimeter (cm) in length (l) and 0.6 cm in width (w) and 0.1 cm depth (d). --10/05/18 - Nursing assessment- Coccyx- dressing intact, see detailed initial pressure ulcer assessment (dated 10/02/18). Right inner foot - see detailed non-pressure wound evaluation. (None could be found). --10/08/18- Coccyx- Stage II- measured 0.8 cm l and 0.4 cm w. and 0.1 cm in depth. --10/09/18-Initial assessment-right inner heel- Stage II- blister which had ruptured and measured 3.0 cm in l and 3.5 cm in w and 0.1 cm in d. --10/17/18- coccyx- stage II- measured 0.4 cm l and 0.1 cm w. and 0.1 cm in depth right heel Stage II- measured 2.2 cm l and 3.0 cm w. and 0.1 cm in depth --10/24/18- coccyx- stage II- measured 0.4 cm l and 0.1 cm w. and 0.1 cm in depth right heel- Unstageable- measured 1.0 cm l and 1.5 cm w. and unknown depth-area with da ark red scab surrounding area red and blanches --10/31/18- coccyx- stage II- area closed right heel Unstageable- area with dark red scab surrounding area red and blanches. measured 1.0 cm l and 1.5 cm w. and depth unknown. --11/05/18- Initial Assessment- left trochanter (hip) Suspected deep tissue injury 1.5 cm in length and 1.5 cm width and unknown depth. Wound bed is dark purple in color --11/07/18- coccyx stage II- area closed for 2 weeks however surrounding skin is dark red and does not blanche. right inner heel Unstageable- area with dark red scab surrounding area red and blanches left trochanter (hip) Suspected deep tissue injury 1.5 cm in length and width and unknown depth. Wound bed is dark purple in color --11/14/18- right inner heel Unstageable- area with dark red scab surrounding area red and blanches measured 2.0 cm l and 2.0 cm w. and unknown in depth. --11/15/18- coccyx- stage II- area closed no redness noted. left trochanter (hip) - area closed red but blanches. --11/21/18- coccyx Suspected deep tissue injury- area 8 cm in length and 6 cm in width and unable to determine. right inner heel Unstageable- area with dark red scab surrounding area red and blanches --11/22/18- Initial assessment: Left heel- blister measured 3 cm x 3 cm unstageable. coccyx stage II- area closed for 2 weeks however surrounding skin is dark red and does not blanche. right inner heel Unstageable- area with dark red scab surrounding area red and blanches left trochanter (hip) Suspected deep tissue injury 1.5 cm in length and 1 cm in width and unknown depth. Wound bed is dark purple in color. b) Resident #14 Review of Resident #14's medical record revealed she was admitted to the facility on [DATE]. Further review found the following nursing assessments and wound assessments found: --Initial wound assessment -07/10/18- right buttock- Stage 2- measured 1.5 cm in l and 1.0 cm w and 0.1 cm in d. Follow wound assessments: --7/17/18- right buttocks - Stage 2- measured 2.0 cm in l and 2.0 cm w and 0.1 cm in d. --7/24/18- right buttock- Stage 2- measured 2.0 cm in l and 1.4 cm w and 0.1 cm in d. --7/31/18- right buttock- Stage 2- measured 2.0 cm in l and 1.3 cm w and 0.1 cm in d. --8/7/18- right buttock- Stage 2- measured 2.8 cm in l and 1.2 cm w and 0.1 cm in d. --8/14/18- right buttock- Stage 2- measured 2.0 cm in l and 1.0 cm w and 0.1 cm in d. --8/21/18- right buttock- Stage 2- measured 2.0 cm in l and 1.2 cm w and 0.1 cm in d. --08/28/18- right/left buttocks- Stage 2- measured 13.0 cm in l and 11.0 cm w and 0.1 cm in d. Additional notes: Area has now spread to left buttock, entire area is dark red/purple, warm to touch and does not blanche. Has multiple open areas varying in sizes, complaint of itching, bowel movements are now soft and formed, allows staff to turn more frequently, fluid intake fair. Wound care provided. --8/31/18-Nursing assessment: Stage II - sacrum- measured 13.0 cm in l x 11.0 cm in w. Multiple areas draining small amount of bright red fluid draining , no odor present. Stage II observed to sacral area- skin warm dark red/purple, non-blanchable, multiple open areas, small amount of bright red drainage present. --9/4/18- right and left buttocks- Stage II- measured 10.2 cm in l and 10.5 cm in l and 0.1 cm in d. four (4) open areas remain. --09/12/18- right and left buttocks- Stage II - measured 9.6 cm in l and 9.0 cm in l and 0.1 cm in d. three (3) open areas. --09/12/18- Nursing Assessment- right buttock and left buttock- Both reads: Unable to observe due to bordered foam dressing. No drainage or odor noted. --09/18/18- #1) coccyx - Stage II Stage II- measured 3.7 cm in l and 2.5 cm in l and 0.1 cm in d. - Area was being measured as one big area, but now open in multiple areas. Scant amount of bloody drainage observed, no odor observed. #2) - right buttock- Stage II-- measured 1.0 cm in l and 0.5 cm in l and 0.1 cm in d #3) left buttock- Stage II- measured 2.0 cm in l and 0.8 cm in l and 0.1 cm in d. --9/25/18 #1- coccyx- Stage II- measured 3.7 cm in l and 2.4 cm in l and 0.1 cm in d. #2 left buttock- Stage II- measured 2.0 cm in l and 0.7 cm in l and 0.1 cm in d. #3- right buttock- Stage II- measured 0.8 cm in l and 0.5 cm in l and 0.1 cm in d. --10/02/18- #1- coccyx- Stage II- measured 3.0 cm in l and 2.4 cm in l and 0.1 cm in d. #2 left buttock- Stage II- measured 0 cm in l and 0 cm in l and 0 cm in d. #3- right buttock- Stage II- measured 0.4 cm in l and 0.4 cm in l and 0.1 cm in d. --10/09/18- #1- coccyx- Stage II- measured 3.5 cm in l and 1.5 cm in l and 0.1 cm in d. #2 left buttock- Stage II- measured 0 cm in l and 0 cm in l and 0 cm in d. #3- right buttock- Stage II- measured 0.3 cm in l and 0.3 cm in l and 0.3 cm in d. --10/16/18- #1- coccyx- Stage III- measured 3.1 cm in l and 1.5 cm in l and 0.1 cm in d. #2 - right buttock- Stage II- measured 0.5 cm in l and 0.5 cm in l and 0.1 cm in d. --10/23/18- #1- coccyx- Stage III- measured 3.5 cm in l and 1.5 cm in l and 0.1 cm in d. #2 - right buttock- Unstageable- measured 0.5 cm in l and 0.5 cm in l and unknown d. --10/31/18- #1- coccyx- Stage III- measured 3.4 cm in l and 1.3 cm in l and 0.1 cm in d. #2 - right buttock- Unstageable- measured 0.4 cm in l and 0.4 cm in l and unknown d. --11/06/18- #1- coccyx- Stage III- measured 3.0 cm in l and 1.0 cm in l and 0.1 cm in d. #2 - right buttock- Unstageable- measured 0.2 cm in l and 0.3 cm in l and unknown d. --11/13/18- #1- coccyx- Stage III- measured 3.1 cm in l and 1.0 cm in l and 0.1 cm in d. #2- right buttock- Healed. --11/27/18- #1- coccyx- Stage III- measured 2.8 cm in l and 1.0 cm in l and 0.1 cm in d. The updated staging system developed by the National Pressure Ulcer Advisory Panel (NPUAP) includes the following definitions: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage IV. Interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 11/28/18 at 3:30 pm confirmed the nursing assessments and the wound sheets were not consist and accurate in type of wound, staging and location. they confirmed they had identified the inconsistency. c) Resident #9 Resident #9 was interviewed on 11/26/18 at 10:52 AM. She was noted to have a 4x4 secured with tape on the front of her right lower leg. Resident #9 stated she also had an open area on the back of her right lower leg. She stated she had completed a course of antibiotics for [MEDICAL CONDITION] but continued to have weeping of fluid from her leg requiring a dressing. Review of Resident #9's medical records revealed she had a [DIAGNOSES REDACTED]. There was no documentation of the application of a dressing to Resident #9's right lower leg. There were no physician orders regarding the application of a dressing to Resident #9's right lower leg. On 11/28/18 at 1:46 PM, Resident #9 was observed in her wheelchair in the hallway outside her room. She stated she did not have a dressing on her right lower leg at that time. She stated she was waiting for a nurse to look at it because she had been having drainage from her leg. While surveyor was speaking to Resident #9, Licensed Practical Nurse (LPN) #108 took Resident #9 into her room to assess her right lower leg. LPN #108 stated Resident #9 had an open area on the back of her right lower leg. LPN #108 stated she would have the unit's Clinical Care Supervisor (CCS) assess the area. On 11/28/18 at 2:35 PM, Resident #9 was observed in the hallway in her wheelchair. She had a dressing on her right lower leg. A wound assessment written by LPN #108 11/28/18 at 2:03 PM stated, An evaluation of this patient's wound was completed by this nurse. Wound location is: Posterior RLE (right lower extremity). Interventions for treatment and healing of this wound are contained in the patient's physician orders and interdisciplinary plan of care. Monitoring and re-evaluation of this wound will be on-going. A wound evaluation- non-pressure wound assessment was completed by LPN #108 on 11/28/18 at 2:03 PM. The wound evaluation stated, Resident c/o (complained of) sock feeling wet. UCN (unit charge nurse) assessed area. RLE with weeping vascular area that measures 1.5x 1cm x less than 0.1 cm. Area is moist and pinkish white in color. Active clear drainage noted. No odor noted. Resident does have [MEDICAL CONDITION] to BLE. (Physician's name) notified. New orders to cleanse area with skin-tegrity pat dry, apply ABD (abdominal) pad and cover with kling. Resident is not a candidate for increase in diuretics due to renal function. AMA (against medical advice) on file for refusals of ace wraps to BLE (bilateral lower extremity) and is also non-compliant with that at times. Resident aware of above. A physician's order written on 11/28/18 at 2:08 PM stated, Cleanse vascular area to RLE with skin-tegrity, pat dry, apply ABD pad and cover with kling every shift for weeping vascular area. During an interview on 11/28/18 at 3:30 PM, CCS #19 stated she had no information regarding when the right lower leg dressing observed on Resident #9 on 11/26/18 had been applied or who applied the dressing. CCS #19 was unable to locate any previous documentation regarding this dressing or a prior assessment of Resident #9's right lower leg skin condition. She stated Resident #9's leg was assessed today and a wound care order was obtained from the physician. CCS #19 stated the physician would assess the resident's leg. d) Resident #43 On 09/17/18, Resident #43 was transferred to the hospital due to chest discomfort, shortness of breath, and upper extremity [MEDICAL CONDITION]. Resident #43 was discharged from the hospital on [DATE]. The discharge summary provided by the hospital to the facility gave the plan as follows (typed as written): - Discharge back to nurse or not rehab - Resume home medications - Follow up with her regular cardiologist within the next 1-2 weeks - See PCP (primary care provider) within the week - Return if worsening concerns. Review of the medical records did not show evidence Resident #43 had seen a cardiologist within one (1) to two (2) weeks of returning to the facility from the hospital on [DATE]. On 11/07/18, Resident #43 returned to the hospital due to shortness of breath. During an interview on 11/27/18 at 12:20 PM, the Director of Nursing (DoN) was asked if an appointment with Resident #43's cardiologist had been made when she returned to the facility on [DATE] as was recommended by the discharging physician. During an interview on 11/28/18 at 9:44 AM, the DoN confirmed Resident #43 did not see a cardiologist within one (1) to two (2) weeks of returning to the facility from the hospital on [DATE]. The DoN stated on 11/27/18 an appointment with a cardiologist had been made for 12/12/18. e) Resident #345 On 11/26/18 at 11:13 AM, it was noted Resident #345 had an opened wound without any dressing on the bottom of his left foot. During an interview on11/27/18 at 9:31 AM, Licensed Practical Nurse (LPN) #23 looking for current notes about wound on foot. After looking at his foot which it appeared to be dry with a thick callus, an area that appeared to have a hole estimating 3.5 centimeters (cm) by 4 cm, with a yellowish colored layer dipping down. She said that he had this on return to the facility but could not recall when that was. During an interview on 11/27/18 at 12:00 PM, asked DoN about wound care and documentation for the wound on the left foot. It was pointed out to her that the documentation was incomplete and inconsonant. She stated that she would look to see if she can more documentation. During an interview on 11/29/18 at 8:38 AM, Administrator was asked about the wound on the left foot of Resident #345. She was asked if she could follow the skin evaluations and the wound assessments? She stated she aware of the poor documentation and is working on that currently. She agreed that the documentation did not paint a clear picture of his wound and the changes concerning the wound. Review of the medical chart revealed that the Skin Evaluation dates started 1/04/18 thru 08/28/18 never had a statement about the wound on the left foot. On the Wound Assessment portion, the first time it was documented was on 04/09/18. On 05/03/18 was the first time it was documented in the Wound Document portion. On 9/13/18 was the first time any nurse had documented any measurements. Review of the Infections Nursing Notes Portion revealed an infection to the left foot on two (2) separate occasions 05/16/18 thru 05/22/18 he received an antibiotic and then again from 08/21/18/to 08/30/18. At this time on 08/21/18 a culture and sensitivity were obtained. A review of the medical records revealed the Nurses were referring to this wound an avulsion (is when skin is pulled off). The Physician who was treating the foot referred to the wound as an ulcer. The Care Plan referred to the wound as a diabetic ulcer. Resident #345 has the following medical Diagnosis: [REDACTED]. f) Resident #59 Review of the residents minimum data set (MDS), a quarterly MDS, with an assessment reference date (ARD) of 10/22/18, found the resident was coded as being occasionally incontinent of urine and frequently incontinent of bowel. Review of the last nursing assessment, dated 10/18/18, found the resident was coded as using the toilet or bedpan and having no episodes of incontinence of urine or bowel. At 9:54 AM on 11/28/18, the Registered Nurse Assessment Coordinator (RNAC) #47, said the nursing assessment was incorrect. RN #47 provided documentation from the nursing assistants to verify the MDS was correct and the nursing assessment was incorrect. RNAC #47 said the nursing assessment should have coded the resident as having episodes of incontinence of both urine and bowel. At 11:56 AM on 11/28/18, the director of nursing (DON) confirmed the nursing assessment was incorrect. On 11/28/18 at 3:18 PM, the documentation on the nursing assessment and the MDS was discussed with the administrator and the vice president of quality care, [NAME] #136. No further information was provided before the close of the survey at 12:15 PM on 11/30/18.",2020-09-01
538,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,690,D,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy review the facility failed to ensure residents, with an indwelling catheter, received the appropriate care based upon current professional standards of practice and services to prevent urinary tract infections to the extent possible. Also failed to ensure the indwelling Foley catheter was secured to the leg was used to prevent injury, accidental removal. This was true for two (2) of two (2) reviewed for catheter care. Identified Residents were Resident #70 and #6. Facility Census 97. Findings included: a) Resident #70 During an interview on 11/26/18 at 11:39 AM, Resident's husband said that she has ESBL in urine she has a catheter. On 11/28/18 at 9:23 AM, Indwelling Foley Catheter care observation with Nursing Assistant (NA) #40, it was noted the catheter anchor was not on the resident's leg. NA#40 wiped once down the sides of the inner legs (groin area), one down stroke over the outside of the vagina. She then emptied the water basin and left room. When she returned with clean wash cloth and water she wiped the catheter tubing but not at the insertion site, only a section of the tubing about 3 inches from the vagina. Licensed Practical Nurse (LPN) #27 brought in a thigh strip to secure the Foley catheter to the leg. NA #85 wiped the buttock crevices toward the vagina, not away from the vagina to prevent Infections. After the two (2) NAs had finished and put the supplies away they were asked the following; - How often are they in-serviced on catheter care? They both said the last time was in (MONTH) this year. - How do they believe they did? NA # 85 said that, she knew that she should not have wiped towards the vagina and NA #40 said she normally does a better job. Both NAs agreed they did not use proper technic for catheter care. During an interview on 11/28/18 at 10:04 AM, DoN was notified of findings that were observed. She stated that she was disappointed. The Facility Policy, Catheter Care, Urinary Dated; 8/2002. reads: -Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note; Catheter tubing should be strapped to the resident's inner thigh.) - report unsecured catheters to the Charge Nurse. The Facility Policy, Perineal Care Dated, 1,2002, reads: -Wash perineal area wiping from front to back. -Separate labia and wash area downward from front to back - gently wash the juncture of the tubing from the urethra down. -Continue to wash the perineum moving from inside outward to and including the thighs alternating from side to side and using downward [MEDICAL CONDITION]. Do not use the same washcloth or water to clean the urethra or labia. -Wash the rectal area thoroughly, wiping the base of the labia towards and extending over the buttocks, do not use the same washcloth or water to clean the labia. Care Plan from electronic chart: Resident #70 has an Indwelling Catheter for [MEDICAL CONDITION] bladder, 16 FR with 10cc balloon. Patient will be/remain free from catheter-related trauma through review date. Change catheter every 4 weeks and as needed. Document pain/discomfort/intolerance due to catheter and report to physician as necessary. Document/report to physician s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Provide patient-specific catheter care as ordered URINARY CATHETER: Patient has a Foley. Position drainage bag and tubing below the level of the bladder to allow free flow of urine into the bag. Secure tubing. Cover drainage bag with appropriate privacy bag. Report any concerns to the Unit Charge Nurse. Provide catheter care and record volume of urine every shift. b) Resident #6 On 11/26/18 at 1:35 pm, an observation with Employee #52, Clinical Care Supervisor (CCS) found Resident #6 had an indwelling Foley Catheter. The catheter was not anchored to the resident's leg. Care Plan from electronic chart reviewed: Focus: Resident #6 has an Indwelling Catheter due to a pressure ulcer on coccyx, 20 FR with 10 cc balloon. Goal: Patient will be/remain free from catheter-related trauma through review date. Intervention: 1. Change catheter every 4 weeks and as needed. 2. Document pain/discomfort/intolerance due to catheter and report to physician as necessary. 3. Document/report to physician s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Provide patient-specific catheter care as ordered 4. URINARY CATHETER: Patient has a Foley. Position drainage bag and tubing below the level of the bladder to allow free flow of urine into the bag. Secure tubing. Cover drainage bag with appropriate privacy bag. Report any concerns to the Unit Charge Nurse. Provide catheter care and record volume of urine every shift. An interview on 11/27/18 at 10:00 am with the DON, the DON was informed of findings. No further information provided.",2020-09-01
539,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,698,D,0,1,J9FW11,"**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 #16 a [MEDICAL TREATMENT] patient received care and services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Resident #16 reported that she is late to [MEDICAL TREATMENT] frequently because the ambulance is always late to get her. Also, Resident #16 had an order for [REDACTED]. This was true for one (1) of one (1) residents reviewed for the care area of [MEDICAL TREATMENT] during the long term care survey process. Resident Identifier: #16. Facility Census: 97 Findings Include: a) Resident #16 1. Transportation to [MEDICAL TREATMENT] During an interview with Resident #16 at 12:00 p.m. on 11/26/18, she stated, I am late for [MEDICAL TREATMENT] on a regular basis. She indicated her appointment was set for 12:00 p.m. and the ambulance often times picked her up after her scheduled appointment time. She stated, I am supposed to be on the machine all ready and I am still sitting her waiting for them to come and get me. She stated, This happens at least once or twice a week. At 12:16 p.m. on 11/26/18, the ambulance company was observed arriving to pick up resident #16 for her [MEDICAL TREATMENT] appointment which was scheduled at 12:00 p.m. A review of Resident #16's medical record at 9:26 a.m. on 11/28/18 found the following physician order [REDACTED].>Further review of the record found the following dates which Resident #16 was picked up for her [MEDICAL TREATMENT] appointment after her scheduled appointment time: All notes are entered by nursing and are appointment/outing notes. The times used are the effective times of the note which would be the time Resident #16 left the building in route to her [MEDICAL TREATMENT] treatment: 07/18/18 at 12:45 p.m. 08/01/18 at 12:55 p.m. 08/27/18 at 12:03 p.m. 09/04/18 at 1:32 p.m. 09/14/18 at 12:19 p.m. 09/24/18 at 12:51 p.m. 09/28/18 at 12:02 p.m. 10/08/18 at 12:10 p.m. 11/02/18 at 12:04 p.m. 11/12/18 at 12:47 p.m. 11/26/18 at 12:15 p.m. 11/29/18 at 12:03 p.m. An interview with the local [MEDICAL TREATMENT] center staff at 10:09 a.m. on 11/28/18 confirmed Resident #16 as consistently late to [MEDICAL TREATMENT]. She stated, She is late at least once or twice a week and it puts us behind for the rest of the day. An interview with the Director of Nursing (DON) at 11:47 a.m. on 11/28/18 confirmed the nursing notes indicated Resident #16 was picked up late for [MEDICAL TREATMENT] on the dates mentioned above. She stated they would have to address it with the ambulance company because this is the first she has heard of it. An interview with Clinical Care Supervisor Registered Nurse #52 at 2:10 p.m. on 11/28/18 found she had spoken with the ambulance company and they stated they would try to do better picking up the resident on time. 2. [MEDICATION NAME] A review of Resident #16's medical record at 9:26 a.m. on 11/28/18 found a physician order [REDACTED].) This ordered was entered into the medical record on 10/08/18. A review of the Medication Administration Record [REDACTED] 10/10/18, 10/12/18, 10/15/18, 10/19/18, 10/22/18, 10/26/18, 10/29/18, 10/31/18, 11/02/18, 11/05/18, 11/07/18, 11/09/18, 11/12/18, 11/14/18, 11/16/18, 11/19/18, 11/21/18, 11/23/18, and 11/26/18. During an interview with the DON at 11:47 a.m. on 11/28/18, the above findings were reviewed she stated she would look into it and let me know what she had found. An interview with Clinical Care Supervisor Registered Nurse #52 at 2:10 p.m. on 11/28/18 confirmed Resident #16's [MEDICATION NAME] was not given as directed by the order and the 5:00 a.m. on Monday, Wednesday and Friday was consistently not held as ordered.",2020-09-01
540,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,744,E,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents diagnosed with [REDACTED]. This was true for three (3) of three (3) residents reviewed for the care area of Dementia. Resident identifiers: #44, #45, and #92. Facility census: 97. Findings include: a) Resident #44 Record review found this seventy-five year old female was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. On 06/01/18, the resident's physician prescribed [MEDICATION NAME], an antipsychotic medication, .25 milligrams (mg's) two times a day (BID) for a [DIAGNOSES REDACTED]. In addition to the [MEDICATION NAME], the resident was receiving the following [MEDICAL CONDITION] medications: [REDACTED] [MEDICATION NAME] 200 mg's by mouth at bedtime for Major [MEDICAL CONDITION], recurrent, unspecified. [MEDICATION NAME] 20 mg. daily for anxiety disorder. The resident was also receiving, Memantine 10 mg's BID, for Dementia in other diseases classified elsewhere with behavioral disturbances. ( Memantine ([MEDICATION NAME]) is used to treat moderate to severe confusion (dementia) related to [MEDICAL CONDITION]. It does not cure [MEDICAL CONDITION], but it may improve memory, awareness, and the ability to perform daily functions.) On 11/27/18 at 12:38 PM, Employee #135, the corporate registered nurse (RN)coordinator, said the facility monitors resident behaviors on the psychopharmacological medication monitoring located in the electronic medical record. Review of the psychopharmacological medication monitoring with RN #135, found no behaviors were documented by nursing staff before the physician ordered [MEDICATION NAME]. Nursing notes, from 05/01/18 through 06/01/18, (the day the [MEDICATION NAME] was initiated), were reviewed with RN #135. There were no behaviors documented in the nursing notes to warrant the initiation of [MEDICATION NAME]. Further review of the physician's progress notes in the electronic medical record with RN #135 at 12:38 PM on 11/27/18, found no information regarding the initiation of [MEDICATION NAME]. On the same day the [MEDICATION NAME] was started (06/01/18, the physician also ordered a urinalysis with reflex culture and sensitivity. Review of the laboratory report with RN #135 found the resident did not have a urinary tract infection. On 8/26/18, the pharmacist reviewed the residents medications and recommended a gradual dose reduction of [MEDICATION NAME]. The physician responded with a GDR was clinically contraindicated and the medication was just started on 06/01/18. At 1:52 PM on 11/27/18, RN #135 and the director of nursing (DON) provided a copy of a nursing home visit note from the residents physician, dated 06/01/18. Both employees confirmed this note had not been scanned into the residents medical record even though it was written over over 5 months ago. The physician had written, Patient will not leave her room to attend activities stating, If I leave the bugs will come in my room and get in my bed, I have to keep the door shut to keep the bugs out, they sometimes knock on my window and try to get in. RN #135 and the DON were unable to provide any documentation to verify facility staff were aware of the delusions, attempted to talk with the resident, or provide any non-pharmacological interventions before starting the antipsychotic medication. Neither employee could find any documentation to indicate this behavior had been witnessed by other staff. Review of the residents current care plan with the DON at 9:15 AM on 11/29/18, found the resident was care planned for receiving [MEDICATION NAME] for delusion and hallucinations. The goal of the care plan was: Patient will remain free of drug related complications including movement disorder. Interventions included: Administer medications as ordered and monitor for side effects. Encourage resident to vent feelings. Monitor/record/report to physician as needed side effects and adverse reactions The DON confirmed the care plan did not discuss what staff should do when the resident had delusions and hallucinations. The DON could not demonstrate how the care plan individualized this resident's dementia care needs. At the close of the survey on 11/29/18 at 12:15 PM, no further information had been provided to substantiate other staff members had documented resident behaviors regarding hallucinations and delusions. No further information was provided to substantiate the facility utilized individualized, non-pharmacological approaches to care (e.g., purposeful and meaningful activities). Meaningful activities are those that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. b) Resident #45 Record review found the resident was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED].>[MEDICAL CONDITION], Dementia, and Depression. The resident was admitted with three antidepressants: [MEDICATION NAME], 75 mg. at bedtime, [MEDICATION NAME], 100 mg, three times (TID) a day [MEDICATION NAME] 30 mg. daily. The resident was not admitted with any antisychotic medication. On 01/19/18, the physician added [MEDICATION NAME] for dementia. On 06/12/18, the [MEDICATION NAME] was discontinued. On 06/13/18 [MEDICATION NAME] 20 mg., daily, was added for depression. The [MEDICATION NAME] was discontinued on 08/27/18. On 06/12/18 [MEDICATION NAME] 0.5 mg. three times a day was started for generalized Anxiety disorder. The [MEDICATION NAME] was discontinued on 11/12/18. On 06/26/18 [MEDICATION NAME] was increased from 75 mg. at bedtime to 150 mg. at bedtime. On 09/12/18, the antipsychotic, [MEDICATION NAME] 25 mg., two times (BID) a day was added to the residents medication regime. The resident continues to take the [MEDICATION NAME], and [MEDICATION NAME]. At 1:00 PM on 11/28/18, the Director of Nursing, (DON) was asked where the facility would have documented any behaviors and non-pharmacological interventions before starting the antipsychotic, [MEDICATION NAME]. On 11/28/18 at 02:41 PM, the DON said, I have looked for non pharmacological interventions, there aren't any documented. The DON said the resident was physically aggressive towards staff and other residents. The DON provided a copy of the nurse practioners (NP) visit, dated 09/12/18. The NP noted the resident had been trying to run over other residents with her wheelchair and was refusing to take her medications and cursing at staff. The Medication Administration Record [REDACTED]. According to the documentation on the MAR, the resident had taken all her medications. The DON was asked if the facility had any incident/accident reports regarding the physical aggression towards other residents? Review of the care plan with the DON found the following interventions were to be implemented when the resident exhibited behaviors: Analyze key times, places, circumstances, triggers and what de-escalates behavior and document. assess patients coping skills and support system When patient becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation if response is aggressive staff to walk calmly away, and approach later. Anticipate and meet patients needs to reduce behavioral symptoms. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take patient to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location time of day persons involved and situations. Document behaviors and potential causes. Report findings to attending physician and or update care plan as appropriate. Privately discuss inappropriate behaviors with patient and explain why his her behavior is unacceptable in the nursing facility. Document discussion. Report outcome to physician and or update care plan as appropriate. The DON was asked to provide information to substantiate the above approaches were implemented as directed by the care plan. During an interview with the DON and administrator on 11/29/18 at 10:34 AM, the DON said, I have nothing else to give you. c) Resident #92 A review of Resident #92's medical record at 12:03 p.m. on 11/28/18 found a physician's orders [REDACTED]. This was ordered on [DATE] by Resident #92's attending physician. The physician progress notes [REDACTED].ORIENTATION: Normal- Alert and orientated X 1. Affect is broad. No visible signs of anxiety or depressed state. Patient is delusional and manic today. They won't let me take care of my husband like I need to, these dogs treat him awful in here. Care Plan .[MEDICAL CONDITION]: [MEDICATION NAME] .25 mg by mouth BID (twice a day). Continue behavior/affect monitoring. Further review of the medical record found Resident #92 use to be a Nurse Aide and her husband is also a resident at this facility. A review of the record from 07/01/18 through 07/31/18 found no documentation of any behaviors from Resident #92 that would justify the use of an antipsychotic medication. The care plan was reviewed and found the following focus statement added to the care plan on 08/03/18, (Last Name of Resident #92) receives antipsychotic medications ([MEDICATION NAME]) r/t behavior management AEB (as evidenced by ) wandering, attempting to provide care to other residents. The goal associated with focus statement was as follows, Patient will be/remain free of drug related complications including movement disorder, discomfort, [MEDICAL CONDITION], gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. The interventions related to this focus statement and goal include:, Administer medications as ordered. Monitor/document for side effects and effectiveness. Encourage family and friends to visit. Encourage out of room activities, such as church activities and special singing. She likes to visit with her husband who resides at the facility Monitor/record/report to physician prn (as needed) side effects and adverse reactions of psychoactive medications : unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideation's, social isolation, blurred vision, diarrhea, fatigue, [MEDICAL CONDITION], loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to one person. Redirect resident when she attempts to provide care for other residents in the facility. The care plan goal and interventions was added after the medication was started. The care plan contains no non pharmacological interventions and there was no indication any non pharmacological interventions were put into place prior to starting the medication [MEDICATION NAME]. During an interview with the Director of Nursing (DON) at 1:37 p.m. on 11/18/18 the above findings were reviewed with her. She was asked to provide any information the facility had in regards to why Resident #92 was started on [MEDICATION NAME] and for any non pharmacological interventions they had in place prior to starting the medication. An interview with Registered Nurse #52 at 2:12 p.m. on 11/28/18 confirmed there was no documented behaviors in the medical record. She stated they looked to see what behaviors led to Resident #92 being started on [MEDICATION NAME] and there was none documented in the medical record.",2020-09-01
541,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,757,D,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #16's drug regimen was free from unnecessary medications. Resident #16's [MEDICATION NAME] was ordered to be held at certain times on [MEDICAL TREATMENT] days and it was not held as ordered. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications. Resident Identifier: #16. Facility Census: 97 Findings Include: a) Resident #16 A review of Resident #16's medical record at 9:26 a.m. on 11/28/18 found a physician order [REDACTED].) This ordered was entered into the medical record on 10/08/18. A review of the Medication Administration Record [REDACTED] 10/10/18, 10/12/18, 10/15/18, 10/19/18, 10/22/18, 10/26/18, 10/29/18, 10/31/18, 11/02/18, 11/05/18, 11/07/18, 11/09/18, 11/12/18, 11/14/18, 11/16/18, 11/19/18, 11/21/18, 11/23/18, and 11/26/18. During an interview with the DON at 11:47 a.m. on 11/28/18, the above findings were reviewed she stated she would look into it and let me know what she had found. An interview with Clinical Care Supervisor Registered Nurse #52 at 2:10 p.m. on 11/28/18 confirmed Resident #16's [MEDICATION NAME] was not given as directed by the order and the 5:00 a.m. on Monday, Wednesday and Friday was consistently not held as ordered.",2020-09-01
542,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,758,E,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents where not placed on [MEDICAL CONDITION] medication before the facility utilized individualized non-pharmacological approaches to care. Therefore these residents medication could not be proven to necessary. This was true for four (4) of five (5) residents reviewed for the care area of unnecessary medications during the Long term care survey process. Resident identifiers: #92, #45, #44, and #84. Facility census: 97. Findings Include: a) Resident #92 A review of Resident #92's medical record at 12:03 p.m. on 11/28/18 found a physician's orders [REDACTED]. This was ordered on [DATE] by Resident #92's attending physician. The physician progress notes [REDACTED].ORIENTATION: Normal- Alert and orientated X 1. Affect is broad. No visible signs of anxiety or depressed state. Patient is delusional and manic today. They won't let me take care of my husband like I need to, these dogs treat him awful in here. Care Plan .[MEDICAL CONDITION]: [MEDICATION NAME] .25 mg by mouth BID (twice a day). Continue behavior/affect monitoring. Further review of the medical record found Resident #92 use to be a Nurse Aide and her husband is also a resident at this facility. A review of the record from 07/01/18 through 07/31/18 found no documentation of any behaviors from Resident #92 that would justify the use of an antipsychotic medication. During an interview with the Director of Nursing (DON) at 1:37 p.m. on 11/18/18 the above findings were reviewed with her. She was asked to provide any information the facility had in regards to why Resident #92 was started on [MEDICATION NAME] and any non pharmacological interventions they had put into place prior to starting the medication. An interview with Registered Nurse #52 at 2:12 p.m. on 11/28/18 confirmed there was no documented behaviors in the medical record. She stated they looked to see what behaviors led to Resident #92 being started on [MEDICATION NAME] and there was none documented in the medical record. She also confirmed there was no documented non pharmacological interventions in the medical record prior to starting Resident #92 on [MEDICATION NAME]. b) Resident #44 Record review found this seventy-five year old female was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. On 06/01/18, the resident's physician prescribed [MEDICATION NAME], an antipsychotic medication, .25 milligrams (mg's) two times a day (BID) for a [DIAGNOSES REDACTED]. In addition to the [MEDICATION NAME], the resident was receiving the following [MEDICAL CONDITION] medications: [REDACTED] [MEDICATION NAME] 200 mg's by mouth at bedtime for Major [MEDICAL CONDITION], recurrent, unspecified. [MEDICATION NAME] 20 mg. daily for anxiety disorder. The resident was also receiving, Memantine 10 mg's BID, for Dementia in other diseases classified elsewhere with behavioral disturbances. ( Memantine ([MEDICATION NAME]) is used to treat moderate to severe confusion (dementia) related to [MEDICAL CONDITION]. It does not cure [MEDICAL CONDITION], but it may improve memory, awareness, and the ability to perform daily functions.) On 11/27/18 at 12:38 PM, Employee #135, the corporate registered nurse (RN)coordinator, said the facility monitors resident behaviors on the psychopharmacological medication monitoring located in the electronic medical record. Review of the psychopharmacological medication monitoring with RN #135, found no behaviors were documented by nursing staff before the physician ordered [MEDICATION NAME]. Nursing notes, from 05/01/18 through 06/01/18, (the day the [MEDICATION NAME] was initiated), were reviewed with RN #135. There were no behaviors documented in the nursing notes to warrant the initiation of [MEDICATION NAME]. Further review of the physician's progress notes in the electronic medical record with RN #135 at 12:38 PM on 11/27/18, found no information regarding the initiation of [MEDICATION NAME]. On the same day the [MEDICATION NAME] was started (06/01/18, the physician also ordered a urinalysis with reflex culture and sensitivity. Review of the laboratory report with RN #135 found the resident did not have a urinary tract infection. On 8/26/18, the pharmacist reviewed the residents medications and recommended a gradual dose reduction of [MEDICATION NAME]. The physician responded with a GDR was clinically contraindicated and the medication was just started on 06/01/18. At 1:52 PM on 11/27/18, RN #135 and the director of nursing (DON) provided a copy of a nursing home visit note from the residents physician, dated 06/01/18. Both employees confirmed this note had not been scanned into the residents medical record even though it was written over over 5 months ago. The physician had written, Patient will not leave her room to attend activities stating, If I leave the bugs will come in my room and get in my bed, I have to keep the door shut to keep the bugs out, they sometimes knock on my window and try to get in. RN #135 and the DON were unable to provide any documentation to verify facility staff were aware of the delusions, attempted to talk with the resident, or provide any non-pharmacological interventions before starting the antipsychotic medication. Neither employee could find any documentation to indicate this behavior had been witnessed by other staff. Review of the residents current care plan with the DON at 9:15 AM on 11/29/18, found the resident was care planned for receiving [MEDICATION NAME] for delusion and hallucinations. The goal of the care plan was: Patient will remain free of drug related complications including movement disorder. Interventions included: Administer medications as ordered and monitor for side effects. Encourage resident to vent feelings. Monitor/record/report to physician as needed side effects and adverse reactions The DON confirmed the care plan did not discuss what staff should do when the resident had delusions and hallucinations. The DON could not demonstrate how the care plan individualized this resident's dementia care needs. At the close of the survey on 11/29/18 at 12:15 PM, no further information had been provided to substantiate other staff members had documented resident behaviors regarding hallucinations and delusions. No further information was provided to substantiate the facility utilized individualized, non-pharmacological approaches to care (e.g., purposeful and meaningful activities). Meaningful activities are those that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. c) Resident #45 Record review found the resident was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED].>[MEDICAL CONDITION], Dementia, and Depression. The resident was admitted with three antidepressants: [MEDICATION NAME], 75 mg. at bedtime, [MEDICATION NAME], 100 mg, three times (TID) a day [MEDICATION NAME] 30 mg. daily. The resident was not admitted with any antisychotic medication. On 01/19/18, the physician added [MEDICATION NAME] for dementia. On 06/12/18, the [MEDICATION NAME] was discontinued. On 06/13/18 [MEDICATION NAME] 20 mg., daily, was added for depression. The [MEDICATION NAME] was discontinued on 08/27/18. On 06/12/18 [MEDICATION NAME] 0.5 mg. three times a day was started for generalized Anxiety disorder. The [MEDICATION NAME] was discontinued on 11/12/18. On 06/26/18 [MEDICATION NAME] was increased from 75 mg. at bedtime to 150 mg. at bedtime. On 09/12/18, the antipsychotic, [MEDICATION NAME] 25 mg., two times (BID) a day was added to the residents medication regime. The resident continues to take the [MEDICATION NAME], and [MEDICATION NAME]. At 1:00 PM on 11/28/18, the Director of Nursing, (DON) was asked where the facility would have documented any behaviors and non-pharmacological interventions before starting the antipsychotic, [MEDICATION NAME]. On 11/28/18 at 02:41 PM, the DON said, I have looked for non pharmacological interventions, there aren't any documented. The DON said the resident was physically aggressive towards staff and other residents. The DON provided a copy of the nurse practioners (NP) visit, dated 09/12/18. The NP noted the resident had been trying to run over other residents with her wheelchair and was refusing to take her medications and cursing at staff. The Medication Administration Record [REDACTED]. According to the documentation on the MAR, the resident had taken all her medications. The DON was asked if the facility had any incident/accident reports regarding the physical aggression towards other residents? Review of the care plan with the DON found the following interventions were to be implemented when the resident exhibited behaviors: Analyze key times, places, circumstances, triggers and what de-escalates behavior and document. assess patients coping skills and support system When patient becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation if response is aggressive staff to walk calmly away, and approach later. Anticipate and meet patients needs to reduce behavioral symptoms. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take patient to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location time of day persons involved and situations. Document behaviors and potential causes. Report findings to attending physician and or update care plan as appropriate. Privately discuss inappropriate behaviors with patient and explain why his her behavior is unacceptable in the nursing facility. Document discussion. Report outcome to physician and or update care plan as appropriate. The DON was asked to provide information to substantiate the above approaches were implemented as directed by the care plan. During an interview with the DON and administrator on 11/29/18 at 10:34 AM, the DON said, I have nothing else to give you. d) Resident #84 Record review found a seventy eight year old female admitted to the facility on [DATE]. Review of the Medication Administration Record [REDACTED] The resident was admitted with the [MEDICAL CONDITION] medication, [MEDICATION NAME] ([MEDICATION NAME]) 0.25 mg's every 4 hours for anxiety. The [MEDICATION NAME] was discontinued on 11/03/18. A new order for [MEDICATION NAME] was written on 11/03/18 for [MEDICATION NAME] .25 mg's every 8 hours for anxiety. This order was discontinued on 11/04/18. On 11/05/18 another order was written for [MEDICATION NAME] .5 mg's three times a day for anxiety. This order was discontinued on 11/05/17. On 11/05/17, a new order was written for [MEDICATION NAME] .25 mg's three times a day for anxiety. This order was discontinued on 11/06/18. On 11/06/18 another new order was written for [MEDICATION NAME] .25 mg's two times (BID) a day. (The resident is currently receiving [MEDICATION NAME] .25 mg's BID. On 11/06/18 the physician saw the resident at the facility. According to documentation from the physician, the resident told the physician, .she feels like she is very drugged. States, I think I'm getting too much [MEDICATION NAME]. The physician decreased the [MEDICATION NAME] to .25 mg's two times a day. On 11/06/18 the physician also ordered [MEDICATION NAME] 5 mg's daily. On 11/27/18 at 2:00 PM, the Registered Nurse corporate coordinator, RN #135 was asked why the resident was started on the [MEDICATION NAME]? On 11/27/18 at 3:07 PM, RN #135 said she did not know why the physician started the [MEDICATION NAME]. RN #135 was unable to provide documentation of any resident behaviors and unable to provide documentation of any non-pharmacological interventions provided before starting the [MEDICATION NAME]. RN #135 was unable to find documentation as to why the [MEDICATION NAME] orders were changed on five occasions during a 6 day time frame. RN #135 found documentation the resident was complaining of feeling real shaky on the inside and nervous on 11/05/18, so the physician, started her [MEDICATION NAME] back. However, review of the MAR found the resident received [MEDICATION NAME] .25 mg's at 2:00 PM and 10:00 PM. The resident also received [MEDICATION NAME] .5 mg's at 2:00 PM. The [MEDICATION NAME] was not discontinued on 11/05/18-only the dosage was changed. As the orders are entered into the computer electronically and approved electronically by the physician there is no way to determine if the physician's orders [REDACTED]. At the close of the survey on 11/29/18 at 12:15 PM, no further information was provided to verify the resident received non-pharmacological interventions before starting the antidepressant, [MEDICATION NAME]. Also there was not documentation provided to substantiate the resident was exhibiting behaviors indicating she was depressed and required an anti-depressant medication.",2020-09-01
543,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,812,F,0,1,J9FW11,"Based on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner. Bowls and tray covers were not stored inverted and foods that had passed their use by/best by/expiration dates were found in a refrigerator, a food serving area, and the dry storage area. This had the potential to affect all residents in the facility. Facility census: 97. Findings included: a) Kitchen Tour An initial tour of the facility kitchen began on 11/26/18 at 10:23 AM with Dietary Services Supervisor (DSS) #122. During this tour, one (1) individual bowl of prepared salad with a use by date of 11/22/18 was found in a refrigerator containing resident food across from the tray line. DSS #122 removed the salad at the time of the finding. On shelves underneath the tray line, a box labeled Orange Pekoe and Pekoe Cut Black Tea containing 41 loose tea bags was found to have a best by date of 07/12/15. On the same shelves underneath the tray line, stacks of bowls were found facing up, potentially exposing the insides of the bowls to dust, debris, and/or splatter. Numerous tray covers were found on top of the tray line also facing up, potentially exposing the insides to dust, debris, and/or splatters. Once notified of the above issues, DSS #122 removed the box of loose tea bags. She stated that she did not feel that the bowls and tray covers needed to be stored inverted since they were dry. DSS #122 confirmed that the bowls and tray covers were used in serving resident food. She was then asked for a facility policy indicating that it was acceptable not to invert bowls and tray covers to be used in serving resident food. DSS #122 stated she was not aware of any such policy. In the dry storage room, 11 more boxes of Orange Pekoe and Pekoe Cut Black Tea were found. Each box had a best by date of (MONTH) (YEAR) and contained 100 tea bags. One (1) 11-pound container of vanilla creme icing with a use by date of 11/10/18 was also found in the dry storage area. At 10:37 AM, DSS #122 was notified of the findings and removed the outdated items from storage. On 11/29/18 at 10:42 AM, the facility's Director of Nursing (DoN) was informed of the issues. No further information was provided by the facility prior to the end of the survey.",2020-09-01
544,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,865,E,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure the Quality Assessment and Assurance committee made good faith attempts to correct quality deficiencies which it did have or should have had knowledge of. The facility failed to identify the fact that three (3) of three (3) residents reviewed for the care area of dementia management was started on antipsychotic medications when no non pharmacological interventions and been put in place prior to the starting of the medication. This practice has the potential to effect more than an isolated number of residents currently residing in the facility. Resident Identifiers: #92, #44, and #45 Facility Census: 97. Findings Include: a) Treatment/Services for Dementia 1. Resident #44 Record review found this seventy-five year old female was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. On 06/01/18, the resident's physician prescribed [MEDICATION NAME], an antipsychotic medication, .25 milligrams (mg's) two times a day (BID) for a [DIAGNOSES REDACTED]. In addition to the [MEDICATION NAME], the resident was receiving the following [MEDICAL CONDITION] medications: [REDACTED] [MEDICATION NAME] 200 mg's by mouth at bedtime for Major [MEDICAL CONDITION], recurrent, unspecified. [MEDICATION NAME] 20 mg. daily for anxiety disorder. The resident was also receiving, Memantine 10 mg's BID, for Dementia in other diseases classified elsewhere with behavioral disturbances. ( Memantine ([MEDICATION NAME]) is used to treat moderate to severe confusion (dementia) related to [MEDICAL CONDITION]. It does not cure [MEDICAL CONDITION], but it may improve memory, awareness, and the ability to perform daily functions.) On 11/27/18 at 12:38 PM, Employee #135, the corporate registered nurse (RN)coordinator, said the facility monitors resident behaviors on the psychopharmacological medication monitoring located in the electronic medical record. Review of the psychopharmacological medication monitoring with RN #135, found no behaviors were documented by nursing staff before the physician ordered [MEDICATION NAME]. Nursing notes, from 05/01/18 through 06/01/18, (the day the [MEDICATION NAME] was initiated), were reviewed with RN #135. There were no behaviors documented in the nursing notes to warrant the initiation of [MEDICATION NAME]. Further review of the physician's progress notes in the electronic medical record with RN #135 at 12:38 PM on 11/27/18, found no information regarding the initiation of [MEDICATION NAME]. On the same day the [MEDICATION NAME] was started (06/01/18, the physician also ordered a urinalysis with reflex culture and sensitivity. Review of the laboratory report with RN #135 found the resident did not have a urinary tract infection. On 8/26/18, the pharmacist reviewed the residents medications and recommended a gradual dose reduction of [MEDICATION NAME]. The physician responded with a GDR was clinically contraindicated and the medication was just started on 06/01/18. At 1:52 PM on 11/27/18, RN #135 and the director of nursing (DON) provided a copy of a nursing home visit note from the residents physician, dated 06/01/18. Both employees confirmed this note had not been scanned into the residents medical record even though it was written over over 5 months ago. The physician had written, Patient will not leave her room to attend activities stating, If I leave the bugs will come in my room and get in my bed, I have to keep the door shut to keep the bugs out, they sometimes knock on my window and try to get in. RN #135 and the DON were unable to provide any documentation to verify facility staff were aware of the delusions, attempted to talk with the resident, or provide any non-pharmacological interventions before starting the antipsychotic medication. Neither employee could find any documentation to indicate this behavior had been witnessed by other staff. Review of the residents current care plan with the DON at 9:15 AM on 11/29/18, found the resident was care planned for receiving [MEDICATION NAME] for delusion and hallucinations. The goal of the care plan was: Patient will remain free of drug related complications including movement disorder. Interventions included: Administer medications as ordered and monitor for side effects. Encourage resident to vent feelings. Monitor/record/report to physician as needed side effects and adverse reactions The DON confirmed the care plan did not discuss what staff should do when the resident had delusions and hallucinations. The DON could not demonstrate how the care plan individualized this resident's dementia care needs. At the close of the survey on 11/29/18 at 12:15 PM, no further information had been provided to substantiate other staff members had documented resident behaviors regarding hallucinations and delusions. No further information was provided to substantiate the facility utilized individualized, non-pharmacological approaches to care (e.g., purposeful and meaningful activities). Meaningful activities are those that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. 2. Resident #45 Record review found the resident was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED].>[MEDICAL CONDITION], Dementia, and Depression. The resident was admitted with three antidepressants: [MEDICATION NAME], 75 mg. at bedtime, [MEDICATION NAME], 100 mg, three times (TID) a day [MEDICATION NAME] 30 mg. daily. The resident was not admitted with any antisychotic medication. On 01/19/18, the physician added [MEDICATION NAME] for dementia. On 06/12/18, the [MEDICATION NAME] was discontinued. On 06/13/18 [MEDICATION NAME] 20 mg., daily, was added for depression. The [MEDICATION NAME] was discontinued on 08/27/18. On 06/12/18 [MEDICATION NAME] 0.5 mg. three times a day was started for generalized Anxiety disorder. The [MEDICATION NAME] was discontinued on 11/12/18. On 06/26/18 [MEDICATION NAME] was increased from 75 mg. at bedtime to 150 mg. at bedtime. On 09/12/18, the antipsychotic, [MEDICATION NAME] 25 mg., two times (BID) a day was added to the residents medication regime. The resident continues to take the [MEDICATION NAME], and [MEDICATION NAME]. At 1:00 PM on 11/28/18, the Director of Nursing, (DON) was asked where the facility would have documented any behaviors and non-pharmacological interventions before starting the antipsychotic, [MEDICATION NAME]. On 11/28/18 at 02:41 PM, the DON said, I have looked for non pharmacological interventions, there aren't any documented. The DON said the resident was physically aggressive towards staff and other residents. The DON provided a copy of the nurse practioners (NP) visit, dated 09/12/18. The NP noted the resident had been trying to run over other residents with her wheelchair and was refusing to take her medications and cursing at staff. The Medication Administration Record [REDACTED]. According to the documentation on the MAR, the resident had taken all her medications. The DON was asked if the facility had any incident/accident reports regarding the physical aggression towards other residents? Review of the care plan with the DON found the following interventions were to be implemented when the resident exhibited behaviors: Analyze key times, places, circumstances, triggers and what de-escalates behavior and document. assess patients coping skills and support system When patient becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation if response is aggressive staff to walk calmly away, and approach later. Anticipate and meet patients needs to reduce behavioral symptoms. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take patient to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location time of day persons involved and situations. Document behaviors and potential causes. Report findings to attending physician and or update care plan as appropriate. Privately discuss inappropriate behaviors with patient and explain why his her behavior is unacceptable in the nursing facility. Document discussion. Report outcome to physician and or update care plan as appropriate. The DON was asked to provide information to substantiate the above approaches were implemented as directed by the care plan. During an interview with the DON and administrator on 11/29/18 at 10:34 AM, the DON said, I have nothing else to give you. 3. Resident #92 A review of Resident #92's medical record at 12:03 p.m. on 11/28/18 found a physician's orders [REDACTED]. This was ordered on [DATE] by Resident #92's attending physician. The physician progress notes [REDACTED].ORIENTATION: Normal- Alert and orientated X 1. Affect is broad. No visible signs of anxiety or depressed state. Patient is delusional and manic today. They won't let me take care of my husband like I need to, these dogs treat him awful in here. Care Plan .[MEDICAL CONDITION]: [MEDICATION NAME] .25 mg by mouth BID (twice a day). Continue behavior/affect monitoring. Further review of the medical record found Resident #92 use to be a Nurse Aide and her husband is also a resident at this facility. A review of the record from 07/01/18 through 07/31/18 found no documentation of any behaviors from Resident #92 that would justify the use of an antipsychotic medication. The care plan was reviewed and found the following focus statement added to the care plan on 08/03/18, (Last Name of Resident #92) receives antipsychotic medications ([MEDICATION NAME]) r/t behavior management AEB (as evidenced by ) wandering, attempting to provide care to other residents. The goal associated with focus statement was as follows, Patient will be/remain free of drug related complications including movement disorder, discomfort, [MEDICAL CONDITION], gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. The interventions related to this focus statement and goal include:, Administer medications as ordered. Monitor/document for side effects and effectiveness. Encourage family and friends to visit. Encourage out of room activities, such as church activities and special singing. She likes to visit with her husband who resides at the facility Monitor/record/report to physician prn (as needed) side effects and adverse reactions of psychoactive medications : unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideation's, social isolation, blurred vision, diarrhea, fatigue, [MEDICAL CONDITION], loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to one person. Redirect resident when she attempts to provide care for other residents in the facility. The care plan goal and interventions was added after the medication was started. The care plan contains no non pharmacological interventions and there was no indication any non pharmacological interventions were put into place prior to starting the medication [MEDICATION NAME]. During an interview with the Director of Nursing (DON) at 1:37 p.m. on 11/18/18 the above findings were reviewed with her. She was asked to provide any information the facility had in regards to why Resident #92 was started on [MEDICATION NAME] and for any non pharmacological interventions they had in place prior to starting the medication. An interview with Registered Nurse #52 at 2:12 p.m. on 11/28/18 confirmed there was no documented behaviors in the medical record. She stated they looked to see what behaviors led to Resident #92 being started on [MEDICATION NAME] and there was none documented in the medical record. b) QA and A interviews. An interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) at 9:57 a.m. on 11/29/18 confirmed they reviewed antipsychotic medications in the QA and A when they meet monthly. They indicated they had identified they had some issues with documentation of behaviors and non pharmacological interventions but they had not implemented a plan to correct the identified issues. The medications in question were started as early and 06/01/18 and the QA and A committee had numerous months to initiate a plan for improvement, but had failed to do so. and staging was not consistent.",2020-09-01
545,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2017-04-07,279,D,0,1,IF5C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident interview, and staff interview, the facility failed to include non-pharmacological interventions in the plan of care for one (1) of twenty-two (22) resident care plans reviewed. Resident identifier: #129. Facility census: 107. Findings include: a) Resident #129 Review of Resident #129's clinical record conducted, on 04/04/17 at 9:00 a.m., revealed an original admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. Section I J included the active [DIAGNOSES REDACTED]. The admission physician orders [REDACTED]. The current physician orders [REDACTED]. During an interview conducted, on 04/05/17 at 8:59 a.m., Resident #129 stated difficulty with sleeping and required the use of the medication [MEDICATION NAME] to fall asleep. The resident stated the staff did not provide any other interventions to promote sleep. When queried about other interventions to promote sleep that had worked in the past, the resident stated it was helpful to have the television on at night to promote sleep. During an interview, on 04/05/17 at 9:12 a.m., Assessment Nurse Staff #37 verified the resident's care plan did not include non-pharmacological interventions to address the resident's [MEDICAL CONDITION].",2020-09-01
546,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2017-04-07,280,D,0,1,IF5C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident interview, and staff interview, the facility failed to revise the care plan to include the resident's resistance to turning and repositioning interventions for one (1) Resident of twenty-two (22) resident care plans reviewed. Resident identifier: #129. Facility census: 107. Findings include: a) Resident #129 Review of Resident #129's clinical record, on 04/04/17 at 9:00 a.m., revealed an original admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. Section G0110 A, documented the resident required extensive assistance of two staff members for bed mobility. The current plan of care dated 1/21/2017 included the problem as, Resident has impaired skin integrity related to pressure ulcer to right heel, left shoulder, coccyx. The interventions included to utilize positioning devises as appropriate to prevent pressure over boney prominences. The Activities of Daily Living (ADL) care plan included the intervention to provide the resident with extensive assist of two for bed mobility to turn and reposition. During an interview, on 04/04/17 at 1:20 p.m., Licensed Practical Nurse (LPN) #86 stated the resident frequently refused to be turned and repositioned. LPN #86 stated the resident had been educated on the risk versus benefits of turning and repositioning however the resident frequently refused staff assistance to be turned and repositioned. During an interview, on 04/04/2017 at 3:00 p.m., Resident #129 stated he does not like to be turned or repositioned and expressed an understanding of the risk of further pressure ulcer development and possible delay of current pressure ulcer healing by refusing to be turned and repositioned. The resident verified the staff frequently attempted turning and repositioning however the resident routinely refused to allow the staff to turn and reposition him. During an interview, on 04/05/2017 at 8:00 a.m., Assessment Nurse #37 verified the plan of care was not revised to include the resident's frequent refusals for turning and repositioning.",2020-09-01
547,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2017-04-07,282,D,0,1,IF5C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, resident interview and staff interview, the facility failed to implement the plan of care regarding an air mattress for one (1) of twenty-two (22) resident care plans reviewed. Findings include: a) Resident #129 Review of Resident #129's clinical record, on 04/04/17 at 9:00 a.m., revealed an original admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. The current plan of care dated 01/21/2017 included the problem of Resident has impaired skin integrity related to pressure ulcer to right heel, left shoulder, coccyx. The interventions included the use of a low air loss mattress as ordered. Review of the manufacturers guidelines for the Aire Select air mattress included on page 4 the following recommendation to, Check patient at least every 8 hours or once per shift to assure proper system operation, otherwise desired therapy may not occur. Documented on page 6, Comfort Setting Adjustment- Mattress pressure can be adjusted by pressing the soft key to reduce mattress firmness, and the firm key to increase firmness. The resident was discharged to the hospital on [DATE] for altered mental status and was readmitted on [DATE]. Review of the Nursing assessment dated [DATE] assessed the resident had the following skin issues noted: --left lateral 5th toe red intact and measured 1.2 centimeters (cm) x 1.8 cm --left lateral outer foot red intact and measured 1.2 cm x 2.8 cm --right heel open with granulation and deep purple present, and measured 4.5 cm x 5.2 cm x >0.1 depth --left buttock red intact and measured13 cm x 10 cm --coccyx open with granulation and measured 4.2 cm x 3.8 cm x 0.8 cm depth --left lateral lower back red intact and measured 8.6 cm x 10 cm --left lateral medial back open with granulation and measured 3.1 cm x 2.8 cm x 0.1 cm --left lateral upper back open with granulation and measured 5.1 cm x 6.7 cm x 0.1 cm depth During observation, on 04/04/17 at 3:20 p.m., the resident's Aire Select air mattress control setting was set at two out of eight lights which indicated the level of firmness. During an interview at that time the resident stated it feels like I am in a hole it doesn't feel like it is inflated, I am uncomfortable. The resident further stated no one ever routinely monitored the air mattress settings to ensure his comfort. During an interview, on 04/04/17 at 3:25 p.m., Licensed Practical Nurse (LPN) #44 was alerted to the resident's complaint about the air mattress not feeling inflated and being uncomfortable. LPN #44 stated, there is no specific setting for the air mattress it is an alternating air mattress that inflates on its own and nursing does not adjust the air mattress settings. They further stated Central Supply Staff #104 was responsible for monitoring the air mattress settings. During an interview, on 04/04/17 at 3:40 p.m., LPN #86 stated they were unaware of the required settings for the resident's air mattress, they further stated, Central Supply Staff #104 sets up the air mattress we don't do anything with them. LPN #86 verified there was no routine monitoring of air mattresses to ensure they were set appropriately to ensure resident comfort. They further stated they only look at the air mattress settings if the resident complains about the air mattress not being inflated to their comfort level. During observation, on 04/04/17 at 3:44 p.m., LPN #86 verified the resident's air mattress control setting was set at two out of 8 lights. LPN #86 pushed the plus sign on the air mattress control panel over and over and stated, I am not sure how to adjust the air mattress. The resident stated they were uncomfortable and needed the mattress inflated and further stated, it feels like I am in hole. Nurse Aide (NA) #77 entered the resident's room and stated the resident, likes it to be in the middle. NA#77 pushed the plus sign on the air mattress control panel and adjusted the air mattress control settings to 5 lights and then hit the lock button. The resident stated they were now comfortable. NA #77 stated they had been employed at the facility for five years and had not been educated on how to change the firmness setting on an air mattress and stated, I just know what to do. During an interview, on 04/05/17 at 8:47 a.m., Central Supply Staff #104 stated when an air mattress was ordered for a resident they placed the air mattress on the bed. They stated the air mattresses have an automatic mode sensor that adjusts to the resident's weight. They stated they do not routinely monitor the air mattress to ensure the proper settings for resident comfort as indicated in the manufacturer's guidelines.",2020-09-01
548,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2017-04-07,309,D,0,1,IF5C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well being for three (3) of 35 Stage 2 sample residents. One diabetic resident did not receive adequate oversight of foot wear; one resident did not receive physician ordered lab work; and, one resident did not have a physician's orders [REDACTED]. Resident identifiers: #91, #66 and #115. Facility census: 107. Findings include: a) Resident #91 Resident #91's clinical record was reviewed on 04/05/17 at 10:00 a.m. The resident's admitted to the facility was 10/19/16. Review of the Minimum (MDS) data set [DATE] Section C0500 documented the resident's Brief Interview for Mental Status was 11 indicating the resident was moderately impaired. The resident's care plan included a [DIAGNOSES REDACTED]. Section I2900 of the 03/01/17 MDS included the active [DIAGNOSES REDACTED]. Resident #91 was interviewed, on 04/03/17 at 11:00 a.m. The resident stated while he was hospitalized [DATE] through 02/20/17 his size 8.5 shoes had disappeared from his room. He stated he had told staff upon his return his shoes were missing. Staff replaced his shoes with another pair that he believed had come from the lost and found. The resident stated the shoes he had been given and that he was currently wearing were too small. He stated the shoes were too small and were especially tight across the metatarsal area (directly under the shoe's laces). The shoes were black leather tennis shoes with white stretchy shoe laces. On 04/04/17 at 2:00 p.m. while the resident had visitors he removed his shoes and observed for the size. Stamped into the bottom of the shoes was the size: M6W8 - meaning they were a mens' size 6 or a womens' size 8. Review of the resident's Care Plan, on 04/05/17 at 1:15 p.m., revealed a focus area created on 10/28/16 related to the [DIAGNOSES REDACTED]. Observe feet/toes/ankles/soles/heels noting alteration in skin integrity, color, temperature, and cleanliness. Toenails for shape, length and color. Inspect shoes for proper fit. During review of the resident's medical record, on 04/05/17 at 1:15 p.m., the resident's skin assessments were reviewed. Upon the resident's return from the hospital on [DATE] skin documentation indicated a Stage 2 pressure ulcer measuring 1 (centimeter) cm. x 1 cm. was present on the right outer ankle. Since 02/20/17 skin assessments have been completed weekly by nursing staff and dressings have been provided by nursing staff however, the ill fitting shoes were not identified. Interviews were conducted with two of the Nurse Aides (NA) who cared for Resident #91. NAs #23 and #85 were interviewed on 04/05/17 at 3:00 p.m. NA #23 stated the resident dresses himself, including putting on his shoes, and the only time she might see his feet would be at shower time, which is 2 times per week. NA #85 agreed with NA #23 and stated she did not do daily checks of his feet. Review of the shower records, on 04/05/17 at 3:15 p.m. reflected showers had been given but there was no documentation indicating that the resident's feet had been checked or the status of the feet and shoes. The Director of Nursing (DON) was interviewed, on 04/06/17 at 9:30 a.m. regarding implementation of the Care Plan interventions. No documentation regarding daily checks of the resident's shoes was located. On 04/06/17 at 8:45 a.m., the Administrator stated she had measured Resident #91's feet and found his shoe size should be 8.5. She stated new shoes will be purchased and should be delivered on or about 04/10/17. Despite a plan to make daily observations of a diabetic resident's feet, facility staff failed to identify Resident #91's shoes were 2.5 sizes too small, were uncomfortable, and created a potential for skin breakdown for the diabetic resident. b) Resident #66 Review of Resident #66's clinical record, on 04/06/17 at 10:00 a.m., revealed an admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's current physician orders [REDACTED]. The resident's current medication orders included magnesium oxide 400 mg daily to treat hypomagnesium. The most recent FLP, LFT and magnesium level laboratory test was dated 05/26/16. During an interview, on 04/06/17 at 10:30 a.m., the Director of Nursing verified the most recent FLP, LFT and magnesium laboratory test was dated 05/26/2016 and had been due again in (MONTH) (YEAR). The Director of Nursing verified the physician order [REDACTED]. c) Resident #115 According to the 05/01/16 patient security bracelet policy provided by the Director of Nursing (DON), on 04/06/17 at 2:45 p.m., Patient security bracelets (Wander guard) will be inspected per manufacturer's recommendations but at least a minimum of: every shift for placement, and daily for function. Resident #115 was admitted on [DATE] and readmitted on [DATE]. According to the medication review report, [DIAGNOSES REDACTED]. According to the 01/27/17 significant change minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of 6 out of 15. For wandering: behavior of this type occurred daily. The care plan, revised 11/10/16, identified resident exhibits behavior (wandering), known to wander in other resident's rooms uninvited, and wander towards exit door. Interventions included: Utilize and monitor security bracelet per protocol. (This intervention was initiated on 04/5/17) Resident #115 was observed on 04/04/17 at 11:20 a.m. wandering the hallway. She had a wander guard on her ankle. From 04/04/17 through 04/06/17, the resident was observed wandering throughout the facility, in her wheelchair, with a wander guard on her ankle. According to the medication review report, the wander guard was ordered on [DATE] and 04/5/17. The licensed practical nurse (LPN) #115 was interviewed on 4/5/17 at 1:20 p.m. She said there should have been an order for [REDACTED]. The MDS Staff #37 was interviewed on 04/05/17 at 1:30 p.m. She was unable to find a physician order [REDACTED]. The DON #58 was interviewed along with the MDS staff #37 on 04/06/17 at 8:30 a.m. They were supposed to monitor location and functioning of wander guards. They started this monitoring the day before on 04/05/17 for Resident #115. The order was written 04/05/17. At 1:22 p.m., the DON confirmed there was no specific monitoring for this resident.",2020-09-01
549,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2017-04-07,323,D,0,1,IF5C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to investigate and develop interventions for a resident who has experienced falls, or who is identified as having risk factors for falling for one (1) of three (3) residents reviewed for accidents out of 35 sample residents. Specifically, the facility failed to ensure a fall investigation was completed for resident #98. Resident identifier: #98. Facility census: 107. Findings include: a) Resident #98 According to the 08/01/16 accidents/ incidents policy provided by the Director of Nursing (DON) on 04/06/17 at 2:45 p.m., The staff member must document the incident on the incident/accident investigation form and conduct an immediate investigation of the accident or incident. Include interview of staff and appropriate witnesses .Every attempt shall be made to determine the cause of the accident/ incident and identify intentions to prevent further occurrence. Resident #98 was admitted on [DATE] and readmitted on [DATE]. According to the medication review report, [DIAGNOSES REDACTED]. According to the 01/31/17 significant change minimum data set (MDS) assessment, the resident had severely impaired cognition with a brief interview for mental status (BIMS) score of 5 out of 15. The care plan, revised 02/04/17, identified resident is at risk for falls: cognitive loss, lack of safety awareness, impaired memory, Parkinson's disease, history of falls. Interventions included Bilateral supports on chair and chair alarms for dynergo and geri-chair; Lap buddy, Pommell cushion for positioning; pressure floor alarm; utilize low bed; and place call light within reach. The resident was observed on 04/04/17 at 11:53 a.m. He was in his room in his wheelchair, asleep. He was leaning to the right side with his head on the door. The resident was observed, on 04/05/17 at 7:20 a.m., he was in his wheelchair leaning to the right side. His lap buddy was off on the left side. Additional observations included: --At 8:45 a.m., a pillow was observed under his right side. He was asleep in his wheelchair. His head was leaning forward. --At 9:32 a.m., he remained in his wheelchair, asleep. He was leaning to the right side, with no pillow underneath. An investigation report was completed on 03/27/17, 02/04/17 and 01/29/17. The investigation report for the resident's fall on 3/29/17 was not available. A change of condition evaluation was completed on 03/29/17. For skin changes: no changes observed were marked and the following was provided, Resident had a fall in his restroom, vitals obtained, no complaints of pain or discomfort. The Licensed Practical Nurse (LPN) #115 was interviewed on 04/03/17 at 9:27 a.m. She said this resident had two falls in the last 30 days with a bruise on his knee. The Nurse Aide (NA) #2 was interviewed on 4/5/17 at 7:30 a.m. She said he gets placed either into a geri-chair or a wheelchair with a lap buddy. The resident would try and stand by himself. He was able to use a call light. The DON was interviewed on 04/05/17 at 7:35 a.m. She said she was not aware of the most recent fall that occurred with injury. She discovered that there was a fall with a bruise/ rug burn below the knee. The family was present that day. There was no investigation filed and the nurse that day forgot to do anything with it. The fall was passed on in report. The LPN #136 was interviewed. She said she thought this resident fell on the 29th of March. She said it was an extremely busy day. The resident had a fall. She checked his leg and placed a bandage on it. She spoke with his wife and the physician. She forgot to fill out an incident report. When asked how he fell , she said she knew he was in the bathroom. She was unaware if the fall was witnessed. She said the purpose of an investigation was to keep track and investigate if there was something that should have been done differently. She said she did complete a change in condition and completed neuro checks. She said the resident was found by a NA but was unsure which NA it was. A NA # 93 was interviewed on 04/05/17 at 8:50 a.m. She said she was not there during the fall, but she thought he was found in the bathroom. She said someone placed him in the bathroom. He was found on the floor. The rehab office coordinator #124 was interviewed, on 04/05/17 at 9:10 a.m. He said they had assessed him. He was to be in his chair or his geri-chair. He tended to lean forward or to the side. The LPN ##115 was interviewed again on 04/05/17 at 9:50 a.m. She said this resident did have an injury after this most recent fall. He had a scrape on his right knee. She said it was red and healing well. She noticed it after his fall. She was not working the day of the fall. The NA #107 was interviewed on 04/05/17 at 10:12 a.m. She said she was there the day he fell , but she did not see the fall. She heard his alarm going off and she went to investigate. He was on the floor in his room. She thought he did have an injury. He had pushed his wheelchair back. He was between the dresser and the first bed on the floor. The lap buddy was on the floor. He was in the room, alone. The DON was interviewed again on 04/05/17 at 11:20 a.m. She said she was unaware of the fall until she asked about his knee this week.",2020-09-01
550,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2017-04-07,325,D,0,1,IF5C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to maintain acceptable parameters of nutritional status, such as body weight, unless the resident's clinical condition demonstrates that this is not possible for two (2) of four (4) residents reviewed for nutritional status of 35 sample residents. Specifically, the facility failed to weigh residents per protocol; and provide timely nutritional interventions with weight loss. Resident identifiers: #142 and #138. Facility census: 107. Findings include: a) Facility standards According to the 11/30/15 weights and heights policy provided by the Director of Nursing (DON) on 04/06/17 at 2:45 p.m., Patients are weighed upon admission and /or readmission, then weekly for four weeks and monthly thereafter. Purpose: to obtain baseline weight and identify significant weight change. According to the 11/28/16 nutrition care process policy provided by the DON, on 04/06/17 at 2:45 p.m., Residents with a nutrition [DIAGNOSES REDACTED]. b) Resident #142 Resident #142 was admitted on [DATE] and readmitted on [DATE]. According to the medication review report, [DIAGNOSES REDACTED]. According to the 02/23/17 quarterly minimum data set (MDS) assessment, the brief interview for mental status (BIMS) was not completed. He was an extensive assist with eating. Weight loss was not marked. Height was 67 inches and weight was 122 pounds. The care plan, revised on 04/06/17, identified resident: --is on a dysphagia advanced diet; --had severe weight loss on readmit over the past 30/90 days with continued inadequate oral intake at meals; --had a recent acute illness; --had swallowing changes; and --had a body mass index (BMI) less than 19 placing resident nutritional at risk for skin breakdown. Interventions included: --weight per medical doctor (MD) orders; --alert dietitian and physician to any significant loss or gain; --monitor changes in nutritional status and report to food and nutrition/ physician; --monitor intake at meals and offer alternate choices as needed; and --order house supplement as ordered. The resident was observed on 04/04/17 at 2:22 p.m. The resident was in his bed with the lights off. His body was observed as frail. The resident was observed again on 04/06/17 at 9:37 a.m. He was in bed with a blanket. He had a wander guard on his ankle. According to the weights and vitals summary, labs and skin reports: --04/01/17: 114 pounds (8% loss x 1 month) --03/29/17: Pre-[MEDICATION NAME] level 9.7 low --03/22/17: Pressure areas healed --03/01/17: 124 pounds --02/17/17: House supplement ordered --02/08/17: 126 pounds (readmission 2/9/17- pressure areas on right buttock and coccyx) --02/01/17: 122 pounds --01/29/17: House supplement ordered --01/25/17: 132 pounds --01/18/17: 126 pounds (16.5% loss x 1 month) --12/13/16: 151 pounds --12/06/16: 145 pounds --Admission - Missing weights According to the nutritional assessment on 04/06/17: weight: 114 pounds; regular/ other diet. Weight loss: 8.1% x 1 month. Pressure ulcers not marked. 03/29/17: pre-[MEDICATION NAME] level 9.7 low. Recommend start a house supplement three times daily (TID) x 60 days, start pro-heal liquid one ounce twice daily BID x 60 days. According to the nutritional assessment on 02/15/17: weight: 122 pounds; regular/ other diet. Weight loss: 15.9% x 2 months. Pressure ulcers: right buttock stage II; coccyx stage II. Recommend start a house supplement BID x 30 days. According to the nutritional assessment on 01/23/17: weight: 126 pounds; regular/ dysphagia pureed diet. Weight loss: 16.6% x one month. Recommend start a house supplement BID x 30 days. Recommend a reweigh to validate weight loss. No pressure ulcers marked. According to the nutritional assessment on 12/12/16: weight: 145 pounds; regular diet; no pressure ulcers marked; Goals include: no significant weight changes, no signs/symptoms dehydration, no skin breakdown. Will continue to follow. According to the skin integrity report: open area to the right buttock on 02/09/17- healed on 03/22/17 and pressure area coccyx stage II on 02/09/17- healed on 03/22/17. According to the (MONTH) activities of daily living (ADL) for oral intake: --04/05/17: Breakfast: refused; Lunch: 50%; Dinner: 50% --04/04/17: All meals refused --04/03/17: Breakfast: 100%; Lunch: 50%; Dinner: 75% --04/02/17: Breakfast: 25%; Lunch: 75%; Dinner: 75% --04/01/17: All meals refused (Average meal intake: 33%) According to the (MONTH) ADL for oral intake: (Average meal intake: 50%) According to the (MONTH) ADL for oral intake: (Average meal intake: 46%) According to the progress notes: --03/28/17: Order for [MEDICATION NAME] TID and to obtain labs. --03/27/17: In dining room at this time for dinner. --03/25/17: Resident has slept in bed most of this shift, takes water but refuses solids. --03/23/17: Weight warning: 124 pounds- 7.5% change --030/7/17: Care plan meeting: Weight: 122 pounds, weight loss x 2 months, consumes 48% --03/01/17: Weight warning: 122 pounds- 7.5% change --02/27/17: Resident ate dinner in the dining room. Laboratory records revealed the following: --03/29/17: Pre-[MEDICATION NAME] level: 9.7 low, [MEDICATION NAME]: 2.3 low. physician progress notes [REDACTED].>--03/28/17: Assessment and plan: [MEDICAL CONDITION] of lower extremities- It could be [MEDICATION NAME]. Will watch it carefully and closely. According to the nursing assessment: --02/9/17: Weight: 126 pounds; [MEDICAL CONDITION]- not present. --012/6/16: [MEDICAL CONDITION]- not present. According to the medication review report: --02/17/17: House supplement two times a day for 30 days. --03/31/17 (order date)- 4/3/17: (start date): Check weights every day shift every Monday (while on [MEDICATION NAME]) --03/28/17: [MEDICATION NAME] 5 milligrams (mg)- give one capsule by mouth three times a day for weight loss. The registered dietitian (RD) #135 was interviewed on 4/6/17 at 2:10 p.m. She said this resident #142 continued to receive the supplements ordered although there was a stop date. She said they would request a reweigh for a resident with a five (5) pound weight loss. The Licensed Practical Nurse (LPN) #41 would alert the physician and the team for any residents with weight loss. She said she relied on the electronic medical record for any triggered weight changes. When she completed her assessment, she would look for the current weight in the weight book from LPN #41. They should have started weekly weights for residents with weight loss. She confirmed this resident had a severe weight loss from the admission weight to the current weight. She said she recently increased his supplement to TID. She also said she did not assess/chart on this resident in March. The DON #58 was interviewed on 04/06/17 at 2:45 p.m. When asked if it was a standard to obtain weights on admission and one weekly for four weeks and then monthly, she said Yes. She confirmed that the same process was completed on readmissions. c) Resident # 138 Resident #138 was admitted on [DATE] and passed away on 11/04/16. According to the medication review report, [DIAGNOSES REDACTED]. According to the 10/25/16 14-day MDS assessment, the resident had severely impaired cognition with a BIMS score of 3 out of 15. She was an extensive assist with eating. Weight loss was not marked. Height was 64 inches and weight was 110 pounds. The care plan, revised on 11/07/16, identified resident is on a mechanically altered diet. At present has inadequate oral intake. [DIAGNOSES REDACTED]. BMI is less than 19 placing the resident nutritionally at risk for skin breakdown. Interventions include: weight per MD orders; alert dietitian and physician to any significant loss or gain; Monitor for changes in nutritional status; monitor intake at meals; house supplement as ordered; total assist with all oral intake. According to the weights and vitals summary: --11/01/16: 95 pounds (13.6% loss since admission) --10/20/16: Nutritional assessment- supplements recommended and never started. --10/12/16: 110 pounds (admission) (Missing weights) According to the nutritional assessment on 10/20/16: weight: 110 pounds; regular/ other diet with nectar thick liquids. Pressure ulcers not marked. Recommend start house supplement TID between meals. Intake: Breakfast: 32%, Lunch: 14%, Dinner: 17%. Refused 10 out of 20 meals reviewed. According to the physician certification and re-certification form for 10/12/16: marked for skilled rehab. Admission was signed off on 10/14/16 and the re-certification was signed off on 10/25/16. According to the standing orders on admission, Weights weekly x four, then monthly. physician progress notes [REDACTED].>--10/28/16: Weight marked as stable. --10/21/16: Weight marked as stable. --10/21/16: Appetite is satisfactory. No significant weight change. Plan: Palliative care. --10/14/16: Plan: comfort care. --10/12/16: With newly diagnosed metastatic poorly differentiated [MEDICAL CONDITION] with mets to brain . According to the hospital patient health summary, 10/5/16: weight: 113 pounds. The medication review report was reviewed and void of any supplement orders. The RD #135 was interviewed on 04/05/17 at 10:15 a.m. She said she placed her recommendations on her recommendation form and the form was then given to the DON, nursing home administrator (NHA) and the unit managers. From there, the nursing staff would contact the physician. She said speech therapy was working with this resident. This resident was not on hospice. She said the supplements were usually started soon, dependent on fax response. She confirmed there was no order written for any supplements. The LPN #41 was interviewed on 04/05/17 at 10:24 a.m. She said she was in charge of the weights. She would write them down on a clipboard. She placed them into the electronic medical record. She confirmed the standard was to get a weight on the day of admission, weekly x 4 and then monthly. She said this resident did not have any weight orders. When asked about the standard orders for this resident, she said the standard orders are things that can be done but doesn't have to be done. The DON was interviewed on 04/05/17 at 11:05 a.m. She said the standard orders should have been put into the electronic medical record. She said this resident was not eating much. She said it was the responsibility of medical records to place the standard orders into the electronic medical record. She confirmed the weight orders were not on the MAR for this resident. She also confirmed there was no order for supplements in the chart. She said physician response time was an issue. The DON #58 and the MDS staff #37 were interviewed on 04/06/17 at 8:30 a.m. They said the fax was sent to the physician regarding the supplement. They did not have a copy of the fax. They confirmed that this resident should have been weighed weekly, but there were only two weights available.",2020-09-01
551,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2017-04-07,371,E,0,1,IF5C11,"Based on observations, record review and staff interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service in one (1) of one (1) kitchen and one (1) of one (1) dining room. Specifically, the facility failed to utilize hair nets throughout meal production/service. a) Hair Nets 1. Expectations According to the 2013 Food Code from the U.S Department of Health and Human Services, page 51, 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 . 2. Facility Standards According to the personal hygiene policy, revised on 12/01/15, Hair restraints such as hats, hair coverings, or nets are worn to effectively keep hair from contacting exposed food. 3. Observations On 04/03/17 at 12:00 p.m., Cook # 106 was observed serving food from the steam table. She had long curly brown hair in a ponytail with no hairnet. She had a hat that covered the top portion of her head. Her ponytail down her back was uncovered. The main kitchen was observed, on 04/04/17 at 7:27 a.m., Cook #106 was working in the kitchen with a hat and no hairnet covering her long brown ponytail. At 3:05 p.m., she was observed preparing food for the dinner meal: fish, rice and broccoli. She had a hat covering the top portion of her head. There was no hairnet covering her long, ponytail during food production. 4. Staff Interviews The food service director #100, the executive chef #82 and the registered dietitian (RD) #135 were interviewed, on 04/06/17 at 2:10 p.m. The RD and the executive chef confirmed the need for the hairnet in the kitchen.",2020-09-01
552,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2017-04-07,441,D,0,1,IF5C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility protocol review, staff interview, resident interview and observation, the facility failed to implement the facility protocol for the storage of urinals. This affected four (4) out of 33 resident rooms observed during Stage 1 of the Quality Indicator Survey. Facility census: 107. Findings include: a) Storage of urinals Review of the Nursing Department Infection Control Guidelines Care of Patient Equipment, on 04/04/17 at 10:09 a.m., revealed Personal Care Equipment Urinals were to be covered/stored in the patient's bedside cabinet. During observation of room [ROOM NUMBER], on 04/03/17 at 10:56 a.m. and on 04/04/17 at 9:33 a.m., Resident #103 had an uncovered urinal hanging on their bed side rail, the resident stated that is where it is kept. During observation of room [ROOM NUMBER], on 04/03/17 at 10:14 a.m. and on 04/04/17 at 9:33 a.m., Resident #4 had an uncovered urinal hanging on the grab bar in their bathroom. The resident stated the staff used the urinal to empty their indwelling urinary catheter however they no longer required the use of an indwelling urinary catheter. During an interview, on 04/04/17 at 10:53 a.m., the Director of Nursing verified the resident's indwelling urinary catheter had been discontinued on 02/22/17. During observation of room [ROOM NUMBER], on 04/03/17 at 12:34 p.m. and on 04/04/17 at 9:20 a.m., Resident #129 had an uncovered urinal hanging on the grab bar in their bathroom. In addition, the resident's roommate had an uncovered urinal hanging on the grab bar in the shared bathroom. Both urinals were in direct contact of one another. During observation of room [ROOM NUMBER], on 04/14/17 at 7:45 a.m., Resident #61's urinal was observed on the top of the HVAC unit in their room. The urinal was 1/2 full with urine. The resident stated they placed the urinal there and that he empties and stores his own urinal. During interview, on 04/04/17 at 10:00 a.m., the Director of Nursing verified the observations and stated when not in use the urinals were to be covered.",2020-09-01
553,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2017-04-07,514,D,0,1,IF5C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interview, the facility failed to maintain complete documentation related to pain medication administration for one (1) of three (3) sampled residents reviewed for the care area of Pain Management. Narcotic medications had been accessed and signed out however there was no documentation that they had been administered to the resident. Resident identifier: #91. Facility census: 107. Findings include: The resident's record was reviewed, on 04/05/17 at 10:00 am. The resident's admitted to the facility was 10/19/16. Review of the 03/01/17 Minimum Data Set Section J0100 documented the resident had received an as needed (or prn) pain medication within the 5 days preceding the pain assessment. Sections J0300 and J0400 confirmed the resident experienced pain frequently. And, Section J0600 identified the level of pain to be 8 out of 10. The Brief Interview for Mental Status was 11 indicating the resident was moderately impaired. Resident #91's physician's orders [REDACTED]. Resident #91's Narcotic Record and Medication Administration Record (MAR) for the month of (MONTH) were reviewed, on 04/05/17 at 2:15 p.m., and the revealed the following discrepancies: --On 04/03/17, the narcotic medication Noro 5-325 had been signed out three (3) times from sample Resident #91's narcotic supply in the medication cart and documented in the narcotic book three (3) times, at 5:00 a.m., 11:15 a.m. and 7:30 p.m. Resident #91's Medication Administration Record (MAR) only reflected one (1) administration for 04/03/17 at 11:15 am. The 5:00 a.m. and 7:30 p.m. medications accessed from the narcotic supply were unaccounted for on the MAR. --On 04/01/17 at 6:30 a.m., Noro 5-325 had been signed out from the narcotic supply in the medication cart for sample resident #91 however there was no documentation on the resident's MAR that the medication had been administered. During interview with Resident #9, on 04/03/17 at 11:00 a.m., the resident stated he had received a pain medication earlier in the morning and he was due for one at that time. The resident was observed asking for and receiving a pain medication at 11:15 a.m. The Director of Nursing was interviewed, on 04/05/17 at 9:30 a.m. She was unaware the MAR and narcotic record documentation were inconsistent. At 2:00 pm on 04/05/17, the DON stated a partial audit had been conducted of the facility's narcotic records and no additional discrepancies had been noted. A follow-up interview was conducted with Resident #91, on 04/06/17 at 12:00 p.m., and he confirmed he had received the pain medications in question. The facility policy regarding documentation of narcotic medications requires staff to document within the narcotic record/book when a medication is accessed as well as within the receiving resident's MAR. Additional documentation is required regarding the effectiveness of the medication. The facility failed to reconcile the narcotic medication with the resident's MAR on three occasions, two times on 4/3/17 and one time on 4/5/17.",2020-09-01
554,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2018-06-07,583,D,0,1,DSK711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure personal privacy and confidentiality of health information for a resident. A treatment powder with a pharmacy label containing personal and medical information for a resident was left unattended in a shower room. Personal identifiers including a resident's name, date of birth, medication, and physician, were easily accessible for anyone to view. This was a random observation. Resident identifier: #18. Facility census: 100. Findings included: a) Resident #18 A random observation of the 200 Hall Shower Room, on 06/04/18 at 11:40 AM, revealed one (1) container of [MEDICATION NAME] Topical Powder for Resident #18 was left unattended on a shelf. The container with the pharmacy label attached contained the following information: --Resident's name --Date of birth --Medication --Physician An interview with Registered Nurse (RN) #91, on 06/04/18 at 11:45 AM, revealed the Resident's treatment powder should not have been left in the shower room. The RN stated a resident's personal and medical information should always be protected from others.",2020-09-01
555,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2018-06-07,584,E,0,1,DSK711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide maintenance services for four (4) of sixty (60) rooms observed during the Long Term Care Survey Process (LTCSP). The issues identified included resident's rooms and bathrooms with scratched walls, stained and torn ceiling tiles, discolored caulking on sinks and toilets, and missing floor tiles. Room identifiers: #200, #205, #510, #514, and the 500 Hall Shower Room. Facility census: 100. Findings included: a) Observations The following observations were made on 06/04/18, 06/05/18 and 06/06/18 during the LTCSP: --room [ROOM NUMBER]-The caulking around the bathroom sink and toilet were discolored. --room [ROOM NUMBER]-The bathroom ceiling tile was torn-missing pieces. The caulking around the toilet was discolored. The wall beside the bed was scraped and discolored. --room [ROOM NUMBER]-The ceiling tiles were stained. --room [ROOM NUMBER]-The wall had holes under the clock. The walls were scraped. --500 Hall Shower Room-The first shower stall had missing floor tile. b) Interview An interview with the Maintenance Director, on 06/07/18 at 10:00 AM, revealed room rounds are done daily. The Maintenance Director stated he would ensure the issues were fixed immediately.",2020-09-01
556,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2018-06-07,689,E,0,1,DSK711,"**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. Chemical substances, shaving razors, light bulbs, and toiletries, were unsecured and accessible to residents in shower rooms and a janitor's closet. This practice had the potential to affect more than a limited number of residents. Facility census: 100. Findings included: a) 200 Hall Shower Room A tour of the 200 Hall, on 06/04/18 at 11:30 AM, revealed the Shower Room door was not locked. The Shower Room contained the following items in an unlocked cabinet: --Ten (10) containers of Soothe & Cool Cleanse Shampoo & Body Wash with the warning Avoid contact with eyes. --Two (2) containers of Medspa Shaving Cream with the warning Keep out of reach of children. --One (1) container of Virex II 256 One Step Disinfectant Cleaner & Deodorant with the warning Keep out of reach of children. --Six (6) capped shaving razors. An interview with Registered Nurse (RN) #91, on 06/04/18 at 11:35 AM, revealed the cabinets in the resident bathrooms should always be locked. The RN stated the products found in all Shower Room cabinets should never be accessible to residents. b) 400 Hall Shower Room A tour of the 400 Hall, on 06/05/18 at 8:55 AM, revealed the Shower Room door was not locked. The Shower Room contained the following items in an unlocked cabinet: --Eight (8) containers of Soothe & Cool Cleanse Shampoo & Body Wash with the warning Avoid contact with eyes. --Three (3) containers of Remedy Cleansing Body Lotion with the warning Keep out of reach of children-If swallowed get medical help or call a Poison Control Center. --Thirty-six (36) capped razors. c) 500 Hall Shower Room A tour of the 500 Hall, on 06/05/18 at 9:15 AM, revealed the Shower Room door was not locked. The Shower Room contained the following items in a cabinet that had the key to the lock attached: --Two (2) containers of Remedy Cleansing Body Lotion with the warning Keep out of reach of children-If swallowed get medical help or call a Poison Control Center. --Two (2) containers of Soothe & Cool Cleanse Shampoo & Body Wash with the warning Avoid contact with eyes. --One (1) container of Medline Mouthwash with the warning Keep out of reach of children. --One (1) container of Virex II 256 One Step Disinfectant Cleaner & Deodorant with the warning Keep out of reach of children. --Two (2) containers of Cavi Wipes XL Disinfecting Towelettes with the warning Keep out of reach of children-Hazard to humans and domestic animals. --Sixteen (16) capped razors. d) 200 Hall Janitor's Closet A tour of the 200 Hall, on 06/05/18 at 1:15 PM, revealed the Janitor's Closet door was not shut. The Janitor's Closet contained the following items: --One (1) container of Nitro Wipe Degreaser Towels with the warning Keep out of reach of children-May cause allergic skin reactions. --One (1) container of Mild Acid Detergent with the warning Keep out of reach of children-Causes severe [MEDICAL CONDITION] eye damage-Wear protective gloves and eye/face protection. --One (1) container of Clorox Healthcare Bleach Germicidal Wipes with the warning Keep out of reach of children-Causes moderate eye irritation. --One (1) container of Cavi Wipes XL Disinfecting Towelettes with the warning Keep out of reach of children-Hazard to humans and domestic animals. --Two (2) open light bulbs. An interview with Licensed Practical Nurse (LPN) #26, on 06/05/18 at 1:20 PM, revealed the Janitor's Closet door sometimes sticks and does not shut all the way. The LPN stated the Janitor's Closet should always be locked. The LPN stated she would let the maintenance department know about the door. An interview with the Administrator, on 06/06/18 at 8:30 AM, revealed the cabinets in the shower rooms have had the keys to the locks attached to them forever. The Administrator stated having the keys on the cabinets do allow access to anyone. The Administrator stated she would remove the keys from the shower room cabinets immediately. The Administrator stated maintenance addressed the issue with the 200 Hall Janitor's closet.",2020-09-01
557,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2018-06-07,761,E,0,1,DSK711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy and procedure review, the facility failed to ensure stock medication containers in the medication cart on one hall were dated when opened and put into use and failed to ensure vials of insulin were discarded after expiration dates for two (2) random residents. This practice has the potential to affect more than a limited number of residents. Resident identifiers #18 and #13. Facility census: 100. Findings included: a) An observation of the medication cart on the 500 Hall, on [DATE] at 10:10 AM, revealed the following stock medications were opened and in use, but did not have the date of when the medication was opened. The undated medications included: --1 opened bottle of Senna Plus with no date of when it was opened; --1 bottle of [MEDICATION NAME] with no date of when it was opened; --1 bottle of [MEDICATION NAME] with no date of when it was opened; --1 bottle of [MEDICATION NAME], regular strength with no date of when it was opened; and --1 bottle of Omprazole with no date of when it was opened. An interview with LPN#60 on [DATE], at 10:10 AM verified there was no date on the stock medications listed above, when they were opened and put into use. A review of the facility's policy titled, 5.3, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, dated ,[DATE], revealed, Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. b) Further observation of the medication cart on the 500 Hall, on [DATE], at 10:10 AM, revealed 2 vials of insulin were found to be expired and still present with current medications. 1) A vial of [MEDICATION NAME] for Resident #18, with the expiration date written as [DATE], was observed to be with the current medications. 2) A vial of Humalog for Resident #13, with an expiration date written as [DATE], was observed to be with the current medications. An interview with LPN #60 on [DATE], at 10:10 AM, revealed that the insulin vials had exceeded the written expiration date and was assumed to be what is still given to the residents. An interview with LPN#26 on [DATE], at 10:25 AM, revealed that insulin vials are to be discarded a 28 days after they are opened and these were expired. A review of the Omnicare Insulin Storage Recommendations, dated [DATE], noted that the insulins, Humalog and [MEDICATION NAME], were to be discarded in 28 days after opening when maintained at room temperature. The insulin was maintained in the medication cart at room temperature. A review of the facility's policy titled, 5.3, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, dated ,[DATE], revealed Facility should ensure that medications and biologicals that (1) have an expired date on the label (2) have been retained longer than recommended by manufacturer or supplier guidelines .are stored separate from other medications until destroyed or returned the pharmacy or supplier.",2020-09-01
558,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2018-06-07,880,D,0,1,DSK711,"Based on observation and staff interview, the facility failed to prevent the potential for transmission of infection for 1 of 3 residents, whose catheter bag came into contact with the floor. Resident identifier: #80. Facility census: 100. Findings included: a) Resident #80 On 06/04/18, at 12:05 PM and 06/05/18, at 2:56 PM, Resident #80 was observed in bed with the catheter bag touching the floor. An interview on 06/05/18, at 02:59 PM, with CNA #159, revealed that Resident #80's catheter bag needed emptied and verified the catheter bag was touching the floor. It was further stated by Employee #159 that Hospice had put the resident back to bed and failed to wrap the catheter bag straps enough to keep it off the floor.",2020-09-01
562,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2019-08-01,580,D,0,1,OOIK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to inform and consult with the resident's physician and resident or resident representative of a significant weight loss. This was true for one (1) of three (3) residents reviewed in the care area of nutrition. Identified Resident # 90. Facility census 106. Findings included: a) Resident # 90 During a record review on 07/29/19 at 3:41 PM, revealed, that on 02/01/2019, the resident weighed 189 pounds. On 07/04/2019, the resident weighed 169 pounds which is a -10.58 % Loss. Nutritional assessment 07/23/19 most recent weight 169. on 07/04/19, severe weight loss over 180 days11.1 % loss in 6 months. Dietitian recommended a [MEDICAL CONDITION] panel be done. The last TSH was done on 11/22/18. Resident # 90 lacks capacity, her sister is her MPO[NAME] During an interview on 07/31/19 at 10:45 AM, Registered Nurse (RN) #113 was asked if the [MEDICAL CONDITION] panel was done or ordered. She stated, that the Director of Nursing (DoN) is the one who gets the recommendation sheets, but the last DoN that was here has been gone for about two weeks. She states that she is not sure the dietitian even gave someone the sheet. During an interview on 07/31/19 on 10:55 AM, Director of Nursing (DoN) (who just began this position two (2) days ago), asked Unit Manager #80 if anyone has let the physician know about the recommendation for a [MEDICAL CONDITION] panel and the weight loss. UM #80 was unable to find any documentation of anyone asking the physician about the [MEDICAL CONDITION] panel and notifying him and/or the resident representative of the weight loss. A brief interview on 07/31/19 at 11:05 AM, RN #113 stated, that she prints out a report at the first of the month for the month prior of all weight losses the physician to see all weight losses and he signs them. she would not have notified him of her weight loss until the first of Aug. for the month of July. the last weight was done on 07/04/19. During a brief interview on 07/31/19 at 11:10 AM, DoN agreed that there is not any evidence that the physician or family of Resident #90 of the weight loss. On 07/31/19 at 11:18 AM, Administrator was informed about the physician and resident representative not being notified about the weight loss.",2020-09-01
563,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2019-08-01,636,D,0,1,OOIK11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record review the facility failed to complete an accurate comprehensive assessment for one (1) of twenty-six (26) Minimum Data Sets (MDS) reviewed during the Long Term Care Survey Process (LTCSP). The MDS for R42 did not include oxygen services. Resident identifier: R42. Facility census: 106. Findings include a) R42 During a medical record review on 07/30/19 revealed the MDS with an annual reference date (ARD) of 05/23/19 for R42 had not been coded to reflect oxygen services. Also the current physician's orders [REDACTED]. In an interview on 07/30/19 at 1:10 PM with E84 Clinical Reimbursement Coordinator (CRC) verified the MDS had not been coded to reflect R42 was receiving oxygen services.,2020-09-01
564,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2019-08-01,656,D,0,1,OOIK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record interview and staff interview the facility failed to develop and/or implement the comprehensive care plan for three (3) of 26 sampled residents. The care plan was not implement related to Resident #66 for non-skid footwear. The care plan was not developed for Resident #108 related to end of life choices. The care plan was not implemented for Resident #34 related to bowel protocol. Resident identifiers; #66, #108, #34. Facility census: 106. Findings include: a) Resident #66 Observation on 07/29/19 at 12:51 PM found Resident #66 wearing white footie socks with orange toes. They were not non-skid material. She walked from her wheelchair to her bed slowly, taking numerous small steps. She reached out and held to the bed as she walked. She said she fell on ce recently and did not get hurt. When asked why she was not wearing non-skid footwear, she replied that was her fault. She said she needs to go to Walmart and get some slippers. Observation on 07/29/19 at 2:06 PM found her getting out of bed by herself. She grabbed the wheelchair and pulled it back toward her. She then walked around the wheelchair and sat down in it. She wore white footie socks with orange toes that are not non-skid material. Review of the care plan on 07/30/19 found on page twenty (20) she was deemed at risk for falls and had a history of [REDACTED]. Her most recent falls occurred on 06/20/19 and 06/22/19 related to poor safety awareness. Interventions included to wear non-skid footwear for safety. Further review of the care plan found she requires extensive assistance of one (1) person for transfers with a gait belt. The care plan assessed that she has a history of behaviors which includes walking without assistance. Observation on 07/31/19 at 8:45 AM found her self-propelling in her wheelchair in the 300 hallway and was nearing the end of the hallway circular area. She wore white footie socks with orange toes. This is the second day and third observation of her not wearing non-skid footwear. An interview was completed at this time with licensed nurse #14 (LPN #14), who was present in the hallway. She said this resident is supposed to wear non-skid footwear. She then retrieved a pair of purple, non-skid socks and placed them on the resident's feet in place of the white footie socks with orange toes. These findings of not implementing the care plan for the use of non-skid footwear were reported to the administrator on 08/01/19 at 8 AM. He acknowledged his understanding. b) R108 During a medical record review on 07/30/19, it was discovered the comprehensive care plan had not been developed to include end-of-life choices for R108. In an interview with E111, Licensed Social Worker (LSW) on 07/30/19 at 4:23 PM verified the care plan for R108 had not been developed to include end-of-life choices. c) Resident (R#34) Record review on 07/31/19 on12:20 PM revealed R#34 pertinent [DIAGNOSES REDACTED]. An order dated 06/10/19 stated, Check to see if resident has had BM (bowel movement) and follow BM protocol. Review of BM record revealed in the month of (MONTH) 2019 the resident did not have a BM for seven (7) days between 05/15/19 starting on day shift until 05/22/19 day shift; did not have a BM for three (3) days between 05/23/19 starting on evening shift till 05/27/29 night shift; and did not have a BM for five and a half (5 1/2) days between 05/28/29 night shift through 06/02/19 day shift. Review of R#34's care plan, on 08/01/19 at 08:00 AM, revealed a focus Resident at risk for constipation related to [DIAGNOSES REDACTED]. One of the interventions included Provide medication as ordered ([MEDICATION NAME] scheduled)([MEDICATION NAME] Solution scheduled) ([MEDICATION NAME])(MOM as needed). MOM (milk of magnesium) as needed refers to a laxative used in the facility's bowel regimen/protocol. Another intervention included Provide bowel regimen, utilize pharmacologic agents as appropriate i.e. stool softeners, laxatives, etc, document effectiveness Review of the Medication Administration Record [REDACTED]. The facility failed to implement the resident's care plan interventions regarding constipation. Review of facility's standing orders for bowel regimen/protocol revealed give milk of magnesium (MOM) suspension 400 milligrams (mg)/5 milliliters (ml) give 30 ml by mouth as needed for constipation give it bedtime if no BM in 3 days. Give Ducolax suppository 10 milligram insert one suppository rectally as needed for constipation if no result from MOM by next shift. Fleet enema insert one dose rectally as needed for constipation if no result from Ducolax within 2 hours. If no results from fleet enema, call MD advanced practice provider for further orders On 07/31/19 at 01:04 PM, an interview with licensed practical nurse (LPN#86), revealed the facility's bowel movement protocol is for the nurse to give milk of magnesia if the resident has not had a bowel movement in 3 days. LPN#86 said, If there is no results in 8 hours from the milk of mag then the nurse is to use a suppository. If there's no result from suppository within 2 hours, then the nurses is to use a fleets enema. If there's not any results from the enema, then the nurse is to call the doctor for further orders. LPN#86 confirmed the care plan and BM protocol was not followed.",2020-09-01
565,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2019-08-01,657,D,0,1,OOIK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interview, and resident interview the facility failed to ensure the participation of a resident by failing to timely invite and/or notify of their scheduled care plan meeting. The facility also failed to revise a resident's care plan when a medication identified in the resident's care plan was no longer ordered for the resident. Furthermore, the facility failed to revise a resident's care plan when a resident became totally dependent for eating. This was true for three (3) of twenty-six (26) sample residents care plans reviewed during the annual survey. These practices had the potential to affect more than a limited number of residents. Resident identifier: R#102, R#34, and R#32. Facility census: 106. Findings include: a) Resident (R#102) An interview with Resident (R#102), on 07/29/19 at 04:08 PM, revealed the resident was not invited to her last care plan meeting until after the care plan meeting was held. R#102, who has capacity and is blind, said a letter came to her two (2) days after they had the care plan meeting to notify her of the meeting. R#102 stated she found out about the meeting when someone working in the kitchen asked her why she was not there at her meeting. R#102 stated likes to and wants to go to her care plan meetings. When asked how she knew the letter came two days after the meeting, the resident replied, Because when my mail comes here I have them read it to me right then and there. It was two days after I was told they had had my meeting, when I got the letter. When they read it to me it was telling me about the meeting that was scheduled two days before. On 07/30/19 at 02:35 PM review of a care plan meeting note dated 07/08/19 reveled, Late Entry: 1. Attendance (list all in attendance): see sign sheet 2. Family/resident in attendance (Yes/No, who): see sign sheet 3. Summary of meeting (Brief summary. Details are on care plan): Resident was reviewed in care conference on 7/8/19. Reviewed medications, new orders, labs, code status, capacity, weight & diet, and activity plan. Also reviewed areas to be proceeded with on care plan. Review resident rights and notice of non-discrimination. PAS LTC. Wt 117 eating 43% of meals. Taking [MEDICATION NAME]. Attends OOR activities. 4. Advance directive reviewed (yes/no): post, DNR, capacitated Review of the R#102's care plan meeting's sign in sheets revealed the resident did not attend the (MONTH) care plan meeting but did her previous care plan meetings. An interview, on 07/30/19 at 02:40 PM, with Social Worker (SW#111) revealed she makes the notices for the care plan meetings based on the schedule that the Clinical Reimbursement Coordinator makes. The receptionist then mails all care plan meeting notices. Activities delivers notices to the residents in house. When asked if the facility tracks when notices are sent and any responses they might get back from the notices, SW#111 said no they did not. On 07/30/19 at 03:00 PM, an interview with the Clinical Reimbursement Coordinator (CRC#105) revealed SW#111 creates the care plan meeting notice and the receptionist mails them. Activities staff delivers notices directly to the residents in the facility. CRC#105 said they do not do any follow ups to see if resident received their notices or if they are going to attend. We place all sign in sheets in their record. Review of the resident's sign in sheets revealed the resident did not attend her last meeting. CRC#105 said she was not aware the resident did not get the notice timely. An interview with the Activities Director, on 07/30/19 at 03:10 PM, revealed activities staff deliver mail to the resident. The Activities Director said the resident is blind, and she always has us open her mail right then and there. When asked if it was possible that mail could be left unopen in the resident's room. The Activities Director did not think it was possible for mail to be left unopen in the resident's room, because the resident is always asking us to read it right away and is always asking if she has mail. b) Resident (R#34) Resident (R#34)'s care plan was not revised when a medication identified in the care plan was no longer ordered for the resident. Record review on 07/31/19 on12:20 PM revealed R#34 pertinent [DIAGNOSES REDACTED]. Review of R#34's care plan, on 08/01/19 at 08:00 AM, revealed a focus Resident at risk for constipation related to [DIAGNOSES REDACTED]. One of the interventions included Provide medication as ordered ([MEDICATION NAME] scheduled)([MEDICATION NAME] Solution scheduled) ([MEDICATION NAME])(MOM as needed). Interview with Clinical Reimbursement Coordinator, CRC#105 responsible for developing and revising care plans, on 08/01/19 at 08:49 AM, revealed when physician's orders [REDACTED]. After reviewing current orders CRC#105 agreed [MEDICATION NAME] Solution is no longer scheduled for the resident and the care plan should have been revised when the [MEDICATION NAME] Solution was no longer ordered for the resident. c) Resident (R#32) 's care plan was not revised when the resident became totally dependent for eating. On 07/31/19 at 07:53 AM review of records revealed some pertinent [DIAGNOSES REDACTED]. Review of records revealed the facility failed to revise the resident's care plan after the resident had a change in condition to reflect total dependence on staff for eating. Review of records on 07/31/19 at 07:53 AM revealed a significant change minimum data set (MDS) with an assessment reference date (ARD) of 05/16/19. This MDS showed the resident's cognitive status was greatly impaired, had weight loss and the resident was now totally dependent on staff for eating. Review of nutritional assessment dated [DATE], on 07/31/19 at 09:36 AM revealed . with a decline in ability to feed self . Review of orders revealed physician order [REDACTED]. Staff to feed all po intake. Review of care plan on 08/01/19 at 08:36 AM, revealed supervision to one person assist with eating. On 08/01/19 at 08:56 AM, interview with CRC#105 responsible for developing and revising care plans, revealed the CRC agreed the care plan needed revised to reflect the resident's current status of total dependence on staff for eating.",2020-09-01
566,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2019-08-01,684,E,0,1,OOIK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. This was evident for five (5) of twenty-six (26) sampled residents. The facility did not follow physician's orders [REDACTED].#66; for the prescribed insulin dosage for Resident #72; for the prescribed oxygen flow rate for Resident #42; for standing orders for bowel protocol for Resident #34. The facility did not complete neurological checks for Resident #42 following an unwitnessed fall. The facility did not communicate with the physician regarding the dietitian's recommendations for Resident #90. Resident identifiers: #66, #72, #90, #42, #34. Facility census: 106. Findings include: a) Resident #66 Observation on 07/29/19 at 12:51 PM found Resident #66 wearing white footie socks with orange toes. They were not non-skid material. She walked from her wheelchair to her bed slowly, taking numerous small steps. She reached out and held to the bed as she walked. She said she fell on ce recently and did not get hurt. When asked why she was not wearing non-skid footwear, she replied that was her fault. She said she needs to go to Walmart and get some slippers. Observation on 07/29/19 at 2:06 PM found her getting out of bed by herself. She grabbed the wheelchair and pulled it back toward her. She then walked around the wheelchair and sat down in it. She wore white footie socks with orange toes that are not non-skid material. Review of the medical record on 07/30/19 found physician's orders [REDACTED]. She was deemed a high fall risk, and had a history of [REDACTED]. Her most recent falls occurred on 06/20/19 and 06/22/19 related to poor safety awareness. She had a history of [REDACTED]. Observation on 07/31/19 at 8:45 AM found her self-propelling in her wheelchair on the 300 hallway and was nearing the end of the hallway circular area. She wore white footie socks with orange toes. This is the second day and third observation of her not wearing non-skid footwear. An interview was completed at this time with licensed nurse #14 (LPN #14), who was present in the hallway. She said this resident is supposed to wear non-skid footwear. She then retrieved a pair of purple, non-skid socks and placed them on the resident's feet in place of the white footie socks with orange toes. These findings related to not following physician's orders [REDACTED]. He acknowledged his understanding. b) Resident #72 The medical record was reviewed on 07/30/19. The recapitulation of physician's orders [REDACTED]. 1. Humalog Solution twelve (12) units subcutaneously with meals related to Type 2 Diabetes Mellitus. The start date was 07/04/19. 2. Humalog Solution five (5) units subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus. *Only if blood glucose levels is greater than 200 units give five (5) units. The start date was 07/15/19. Review of the Medication Administration Record [REDACTED]. The dates, times, and blood glucose levels when the resident should not have received the additional five (5) units of Humalog Solution are as follows: 07/17/19 at 4 PM blood sugar (BS)199. The resident received 5 (five) units Humalog in the left arm. 07/18/19 at 4 PM BS was 159. Resident received 5 units Humalog in the right arm. 07/24/19 at 7 AM BS was 199. Resident received 5 units Humalog in the left arm. 07/25/19 at 4 PM BS was 184. Resident received 5 units Humalog in the abdomen. 07/26/19 at 11 AM BS was 151. Resident received 5 units Humalog in the abdomen. 07/27/19 at 11 AM BS was 172. Resident received 5 units Humalog in the abdomen. 07/28/19 at 7 AM BS was 198. Resident received 5 units Humalog in the abdomen. 07/28/19 at 11 AM BS was 153. Resident received 5 units Humalog in the abdomen. 07/29/19 at 11 AM BS was 148. Resident received 5 units Humalog in the right arm. The resident also received the prescribed twelve (12) units of Humalog Solution with breakfast, lunch, and dinner each day from 07/04/19 through 07/29/19. On 07/30/19 at 8:42 AM an interview was conducted with the administrator. It was discussed that this resident received seventeen (17) units of Humalog solution with breakfast, lunch, and dinner from 07/04/19 through 07/29/19, although the physician ordered only twelve (12) units whenever the blood glucose was at or below 200. At 9:03 AM the administrator returned after speaking with the family nurse practitioner (FNP). He said the FNP now wrote a new order to give seventeen (17) units of Humalog Solution with meals three (3) times daily. The administrator said, and showed, that the order for Humalog twelve (12) units subcutaneously with meals, and the order for Humalog five (5) units before meals and at bedtime if the blood glucose level is greater than 200, are both discontinued as of 07/30/19. c) R42 1. During an observation on 07/30/19 at 12:08 PM, it was discovered the oxygen concentrator for R42 was providing an air flow of 1.5 liters via nasal cannula and not the ordered 2 liters. A review of the current physician's orders [REDACTED]. An observation on 07/30/19 at 12:10 PM by E24 Licensed Practical Nurse (LPN) verified the oxygen concentrator was providing an air flow of 1.5 liters and not the ordered 2 liters. 2. During a review of the Risk Management reports, it was discovered R42 had unwitnessed falls on 05/10/19 and 07/03/19. Also reviewed the Falls Management Policy which read: Perform Neurological Assessment for all unwitnessed falls and witnessed falls with head injury. On 08/01/19 at 9:00 AM the Center Nurse Executive (CNE) was unable to locate any neurological checks, which should have been completed after the unwitnessed falls for R42 on 05/10/19 and 07/03/19. d) Resident (R#34) Record review on 07/31/19 on 12:20 PM revealed R#34 pertinent [DIAGNOSES REDACTED]. An order dated 06/10/19 stated, Check to see if resident has had BM (bowel movement) and follow BM protocol. Review of BM record revealed in the month of (MONTH) 2019 the resident did not have a BM for seven (7) days between 05/15/19 starting on day shift until 05/22/19 day shift; did not have a BM for three (3) days between 05/23/19 starting on evening shift till 05/27/29 night shift; and did not have a BM for five and a half (5 1/2) days between 05/28/29 night shift through 06/02/19 day shift. Review of R#34's care plan, on 08/01/19 at 08:00 AM, revealed a focus Resident at risk for constipation related to [DIAGNOSES REDACTED]. One of the interventions included Provide medication as ordered ([MEDICATION NAME] scheduled)([MEDICATION NAME] Solution scheduled) ([MEDICATION NAME])(MOM as needed). MOM (milk of magnesium) as needed refers to a laxative used in the facility's bowel regimen/protocol. Another intervention included Provide bowel regimen, utilize pharmacologic agents as appropriate i.e. stool softeners, laxatives, etc, document effectiveness Review of the Medication Administration Record [REDACTED]. The only time a Ducolax suppository was documented as given was on 05/22/19. There was no record that an enema was ever given to the resident or the physician was notified. Review of facility's standing orders for bowel regimen/protocol revealed give milk of magnesium (MOM) suspension 400 milligrams (mg)/5 milliliters (ml) give 30 ml by mouth as needed for constipation give it bedtime if no BM in 3 days. Give Ducolax suppository 10 milligram insert one suppository rectally as needed for constipation if no result from MOM by next shift. Fleet enema insert one dose rectally as needed for constipation if no result from Ducolax within 2 hours. If no results from fleet enema, call MD advanced practice provider for further orders On 07/31/19 at 01:04 PM, an interview with licensed practical nurse (LPN#86), revealed the facility's bowel movement protocol is for the nurse to give milk of magnesia if the resident has not had a bowel movement in 3 days. LPN#86 said, If there is no results in 8 hours from the milk of mag then the nurse is to use a suppository. If there's no result from suppository within 2 hours, then the nurses is to use a fleets enema. If there's not any results from the enema, then the nurse is to call the doctor for further orders. LPN#86 confirmed the physician orders [REDACTED]. e) Resident # 90 During a record review on 07/29/19 at 3:41 PM, revealed, that on 02/01/2019, the resident weighed 189 pounds. On 07/04/2019, the resident weighed 169 pounds which is a -10.58 % Loss. Nutritional assessment 07/23/19 most recent weight 169. on 07/04/19, severe weight loss over 180 days11.1 % loss in 6 months. Dietitian recommended a [MEDICAL CONDITION] panel be done. The last TSH was done on 11/22/18. Resident # 90 lacks capacity, her sister is her MPO[NAME] During an interview on 07/31/19 at 10:45 AM, Registered Nurse (RN) #113 was asked if the [MEDICAL CONDITION] panel was done or ordered. She stated, that the Director of Nursing (DoN) is the one who gets the recommendation sheets, but the last DoN that was here has been gone for about two weeks. She states that she is not sure the dietitian even gave someone the sheet. During an interview on 07/31/19 on 10:55 AM, Director of Nursing (DoN) (who just began this position two (2) days ago), asked Unit Manager #80 if anyone has let the physician know about the recommendation for a [MEDICAL CONDITION] panel and the weight loss. UM #80 was unable to find any documentation of anyone asking the physician about the [MEDICAL CONDITION] panel and notifying him and/or the resident representative of the weight loss. A brief interview on 07/31/19 at 11:05 AM, RN #113 stated, that she prints out a report at the first of the month for the month prior of all weight losses the physician to see all weight losses and he signs them. she would not have notified him of her weight loss until the first of Aug. for the month of July. the last weight was done on 07/04/19. During a brief interview on 07/31/19 at 11:10 AM, DoN agreed that there is not any evidence that the physician or family of Resident #90 of the weight loss. On 07/31/19 at 11:18 AM, Administrator was informed about the physician and resident representative not being notified about the weight loss.",2020-09-01
567,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2019-08-01,685,D,0,1,OOIK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and medical record review the facility failed to obtain prescription glasses for Resident #66 in a timely manner to maintain optimal visual abilities. This was found for one (1) of one (1) residents reviewed for vision/hearing. Resident identifier: #66. Facility census: 106. Findings include: a) Resident #66 An interview was conducted with this resident on 07/29/19 at 12:48 PM. She said she has trouble seeing with her glasses. She is not wearing her glasses at present. She said she had [MEDICAL CONDITION] removed and should be able to see well with glasses. She said her eyes were examined last year around (MONTH) (2018) and she was supposed to get a new pair of prescription lenses, but she has not yet received them. An interview was conducted with the assistant director of nursing (ADON) on 07/30/19 at 12 PM. She said she thought this resident had new glasses. With the resident's permission, she checked the resident's chest of drawers and found two (2) pairs of glasses. She asked the resident if she could see well out of either pair, to which the resident replied that she could not. The ADON reviewed the medical record and found where this resident had an appointment on 11/19/18 with an optometrist who came to the facility and checked her for complaints of blurred vision and dryness of the eyes. Unit clerk #114 (UC #114) said a prescription for new glasses was written during that visit. She said glasses come in the mail when new ones are prescribed. She said she would contact the company and follow up to see if they mailed hers. On 07/30/19 at 1:15 PM UC #114 said she spoke with a representative from the company who handles the prescription lenses and was told that they were unable to find any record of the glasses having been sent to the resident. She said they told her the resident picked out her frames in (MONTH) (YEAR) at the time of the eye exam. UC #114 also said the representative told her they would complete the paperwork today, and this resident will receive her new glasses in the mail within the next two (2) weeks. An interview was conducted with the administrator on 08/01/19 at 8 AM. He was informed of the lapse in time from the eye exam in November, (YEAR), to the current date of not yet having the new prescription lenses. No further information was provided prior to exit.",2020-09-01
568,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2019-08-01,689,D,0,1,OOIK11,"**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 environment as free of accident hazards as possible. This was evident for one (1) of four (4) residents reviewed for falls. A resident with a known history of falls wore footwear when out of bed which was not non-skid. Non-skid footwear was prescribed for use in her care to promote, supplement, or enhance her safety. Resident identifier: #66. Facility census: 106. Findings include: a) Resident #66 Observation on 07/29/19 at 12:51 PM found Resident #66 wearing white footie socks with orange toes. They were not non-skid material. She walked from her wheelchair to her bed slowly, taking numerous small steps. She reached out and held to the bed as she walked. She said she fell on ce recently and did not get hurt. When asked why she was not wearing non-skid footwear, she replied that was her fault. She said she needs to go to Walmart and get some slippers. Observation on 07/29/19 at 2:06 PM found her getting out of bed by herself. She grabbed the wheelchair and pulled it back toward her. She then walked around the wheelchair and sat down in it. She wore white footie socks with orange toes that are not non-skid material. Review of the care plan on 07/30/19 found on page twenty (20) she was deemed at risk for falls and had a history of [REDACTED]. Her most recent falls occurred on 06/20/19 and 06/22/19 related to poor safety awareness. Interventions included to wear non-skid footwear for safety. Further review of the care plan found she requires extensive assistance of one (1) person for transfers with a gait belt. The care plan assessed that she has a history of behaviors which includes walking without assistance. Review of the medical record on 07/30/19 found physician's orders [REDACTED]. Observation on 07/31/19 at 8:45 AM found her self-propelling in her wheelchair in the 300 hallway and was nearing the end of the hallway circular area. She wore white footie socks with orange toes. This is the second day and third observation of her not wearing non-skid footwear. An interview was completed at this time with licensed nurse #14 (LPN #14), who was present in the hallway. She said this resident is supposed to wear non-skid footwear. She then retrieved a pair of purple, non-skid socks and placed them on the resident's feet in place of the white footie socks with orange toes. These findings of the use of non-skid footwear were reported to the administrator on 08/01/19 at 8 AM. He acknowledged his understanding.",2020-09-01
569,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2019-08-01,690,D,0,1,OOIK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of Center for Disease Control and Prevention (CDC) guideline, and policy review the facility failed to ensure a resident's Foley Catheter drainage tubing was securely anchored and kept below the resident's bladder. This was true of one (1) of three (3) sample residents reviewed for catheter care. This practice had the potential to effect more than a limited number. Resident identifier: R#34. Facility census: 106. Findings include: Record review on 07/31/19 on12:20 PM revealed R#34 pertinent [DIAGNOSES REDACTED]. The resident has a foley catheter and is dependent for all activities of daily living. Observations of Nurse Aide (NA#76) and NA#81 providing catheter care to Resident (R#34), on 07/31/19 at 02:41 PM, revealed the Foley catheter drainage tubing was not secured or anchored in anyway. NA#81 lifted the drainage bag and placed it on top of the bed above the resident's bladder between R#34's legs. The bed was not in the flat position, the foot of the bed was elevated, and the resident's feet was also placed on pillows. The bag was placed on the pillows and urine in the drainage tube started to flow back toward the resident. The NAs did not notice the urine backflowing until surveyor intervention. This surveyor requested NA#81 move the drainage bag so it would not be above resident's bladder, and would stop the urine from returning back into the resident's bladder. The back flow of urine re-entering the resident's bladder would increase the risk for developing an urinary tract infection. During the provision of care the resident was assisted to turn on to her side. The Foley catheter drainage tube was not secured to the resident's leg. Observations, during the repositioning of the resident to expose the areas being cared for, revealed tension and pulling of the drainage tubing. The pulling and tension of the drainage tube had the potential to cause injury to the resident's urethra and urinary meatus. After NA#76 and NA#81 stated they were finished doing catheter care, this surveyor asked what method the facility used to secure the Foley catheter drainage tube. NA#76 acknowledged the resident did not have an anchor device on and confirmed the catheter drainage tubing was supposed to be secured so it did not pull. Review of the facility's Catheter: Indwelling Urinary - Insertion policy revealed #25 stated Ensure the catheter tubing is secured with catheter tube holder or leg strap. Keep the drainage bag below the level of the patient's bladder and off the floor. Review of the facility's policy Catheter: Indwelling Urinary - Care of policy revealed #13 stated Secure catheter tubing holder to keep the drainage bag below the level of the patient's bladder and off the floor. Catheter CDC Current professional standards of practice for maintenance of Foley Catheters include, Do not let the drainage bag touch or lie on the floor. According to the CDC's (Centers for Disease Control and Prevention) Guideline for Prevention of Catheter-Associated Urinary Tract Infections, a directive listed under 'Proper Techniques for Urinary Catheter Maintenance' is Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. According to Lippincott Nursing Center, an authority for the professional development of nurses providing evidence-based procedure guidance; the principles for managing an indwelling catheter include, The collecting bag should be positioned below the level of bladder at all times and never placed on the floor.",2020-09-01
570,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2019-08-01,695,D,0,1,OOIK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview the facility failed to provide respiratory care services, consistent with professional standards of practice. This was true for one (1) of two (2) residents reviewed for respiratory services during the Long Term Care Survey Process (LTCSP). During an observation it was discovered R42 was receiving his oxygen air flow via nasal cannula at 1.5 litters and not the ordered two (2) liters. Resident identifier: R42. Facility census: 106. Findings included: a) R42 During a medical record review on 07/30/19, revealed the physician's orders [REDACTED]. An observation on 07/30/19 at 12:08 PM, it was discovered the oxygen concentrator for R42 had an air flow set on 1.5 liters. An observation by E24, Licensed Practical Nurse (LPN) on 07/30/19 at 12:10 PM verified the oxygen concentrator for R42 was providing an air flow of 1.5 liters and not the ordered two (2) liters per minute.",2020-09-01
571,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2019-08-01,761,D,0,1,OOIK11,"Based on a random observation and staff interview, the facility failed to secure medications properly when the medication cart on C400 hall was left unlocked. This was true for 1 of 4 medication carts. This had the potential to affect more than an isolated number of residents. Facility census: 106. Findings include: On 07/29/19 at 02:49 PM, random observations on C400 hall, revealed the medication cart was unlocked with no staff observed to be in eyesight. Residents were observed walking in the hall. All residents that smoked residing in the facility used the C400 hallway to exit the building to the outside designated area for smoking. The Practice Development Specialist (PDS#1) coming down the hall stopped and confirmed the medication cart was unlocked and should never be unlocked and unattended at any time. The PDS#1 locked the cart and verified any resident or visitor could have access to any of the various medications stored in the cart when it is unlocked.",2020-09-01
572,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2019-08-01,880,E,0,1,OOIK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy review 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 due to inappropriate attire in the laundry room. This had the potential to effect more than a limited number of residents. In addition, this was true for one (1) of one (1) in the care area of catheter care for Resident #34. Facility census 106. Findings included: a) Laundry Facility Policy titled, Soiled linen Handling. -Laundry employees wear proper personal protective equipment (PPE) and perform hand hygiene when sorting and handling soiled linen. -Soiled linens are to sort into labeled bins. During an observation of the clean room on 07/31/19 at 1:45 PM, Laundry Aide #7 was standing and folding sheets when it was noted that she did not have any shoes on. She was asked where her shoes were, she replied they are tucked away right over there (pointing across the room) under that table. During an observation on 07/31/19 at1:56 PM, it was noted that Laundry Aide (LA) #97 was loading a washing machine. She poured the laundry from a clear plastic bag onto the floor in front of the washer and processed to load the machine with only wearing gloves. After she finished loading the washer, she did not change her gloves, she wiped the front of the washer, sprayed and wiped down three (3) pillows, took the pillows to the clean laundry room and placed them on a shelf, she then returned to the soiled laundry room and wiped down the counter tops still wearing the same gloves she was wearing to load the washing machine with soiled laundry. She did not use any hand hygiene. On 07/31/19 at 2:03 PM, Housekeeping Manager # 117 was informed about the observations of LA #97, she was also informed that LA #7 is in the clean laundry room without any shoes on. During an interview on 07/31/19 at 2:20 PM, Administrator was informed of the findings in the laundry room. He shook his head and stated, that he would correct that. b) Catheter care for Resident (R#34) The facility failed to ensure R#34's Foley Catheter drainage tubing was securely anchored and kept below the resident's bladder. Record review on 07/31/19 on12:20 PM revealed R#34 pertinent [DIAGNOSES REDACTED]. The resident has a foley catheter and is dependent for all activities of daily living. Observations of Nurse Aide (NA#76) and NA#81 providing catheter care to Resident (R#34), on 07/31/19 at 02:41 PM, revealed the Foley catheter drainage tubing was not secured or anchored in anyway. NA#81 lifted the drainage bag and placed it on top of the bed above the resident's bladder between R#34's legs. The bed was not in the flat position, the foot of the bed was elevated, and the resident's feet was also placed on pillows. The bag was placed on the pillows and urine in the drainage tube started to flow back toward the resident. The NAs did not notice the urine backflowing until surveyor intervention. This surveyor requested NA#81 move the drainage bag so it would not be above resident's bladder, and would stop the urine from returning back into the resident's bladder. The back flow of urine re-entering the resident's bladder would increase the risk for developing an urinary tract infection. During the provision of care the resident was assisted to turn on to her side. The Foley catheter drainage tube was not secured to the resident's leg. Observations, during the repositioning of the resident to expose the areas being cared for, revealed tension and pulling of the drainage tubing. The pulling and tension of the drainage tube had the potential to cause injury to the resident's urethra and urinary meatus. After NA#76 and NA#81 stated they were finished doing catheter care, this surveyor asked what method the facility used to secure the Foley catheter drainage tube. NA#76 acknowledged the resident did not have an anchor device on and confirmed the catheter drainage tubing was supposed to be secured so it did not pull. Review of the facility's Catheter: Indwelling Urinary - Insertion policy revealed #25 stated Ensure the catheter tubing is secured with catheter tube holder or leg strap. Keep the drainage bag below the level of the patient's bladder and off the floor. Review of the facility's policy Catheter: Indwelling Urinary - Care of policy revealed #13 stated Secure catheter tubing holder to keep the drainage bag below the level of the patient's bladder and off the floor. Catheter CDC Current professional standards of practice for maintenance of Foley Catheters include, Keep the collecting bag below the level of the bladder at all times. According to the CDC's (Centers for Disease Control and Prevention) Guideline for Prevention of Catheter-Associated Urinary Tract Infections, a directive listed under 'Proper Techniques for Urinary Catheter Maintenance' is Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. According to Lippincott Nursing Center, an authority for the professional development of nurses providing evidence-based procedure guidance; the principles for managing an indwelling catheter include, The collecting bag should be positioned below the level of bladder at all times and never placed on the floor.",2020-09-01
573,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2019-08-01,921,E,0,1,OOIK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on random observations and staff interview, the facility failed to ensure their supply room was locked at all times and inaccessible to residents or visitors, thereby failing to provide a safe environment. This had the potential to affect more than a limited number of residents. Facility census: 106. Findings include: a) Central Supply room on the 300 hall A random observation on 07/29/19 at 11:15 AM found the door to the central supply room on the 300 hall unlocked. It could easily be opened by any visitor or wandering resident. The following items which could prove harmful were found inside this central supply room: - A box of one hundred (100) Mediproxen 220 milligram tablets. - A nineteen (19) ounce canister of cavi disinfectant wipes. A warning label stated the wipes cause substantial but temporary eye injury. Active ingredients included [MEDICATION NAME] chloride 0.76%, [MEDICATION NAME] 7.5%, [MEDICATION NAME] 15.00%. - A dozen disposable razors - A pair of scissors - Three (3) suture removal trays with tweezers and scissors - Three (3) screwdrivers - A large box cutter with blade - Numerous bottles of Medline cleanse total body cleanser, Medline shampoo and body wash. The labels directed to avoid contact with eyes as they could burn the eyes. Immediately upon exiting this room, an interview was conducted with nursing assistant #16 (NA #16). When asked if there was a reason this door was not locked, she said someone must not have locked it. She then closed the door and the lock worked. She needed to enter a code on the key-pad lock in order to re-open the door. A second random interview occurred on 07/29/19 at 3:33 PM. The door to the central supply room on the 300 Hall was not locked. It opened and allowed entrance when the door handle was pulled. When the door was securely closed again, it automatically locked itself. An interview was conducted with the administrator on 07/29/19 at 4:00 PM. He was informed that the door to the 300 Hall central supply room was found unlocked on two (2) separate occasions today. It was conveyed that when the door is completely closed it locks itself and requires a code to re-open it. He spoke his understanding that some staff may not be closing the door properly upon exiting the room. This door was not found unlocked again throughout the remainder of the survey.",2020-09-01
574,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2017-10-04,282,D,0,1,TF8J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to implement care plan interventions for a resident with a [MEDICAL TREATMENT] Arteriovenous (AV) fistula/shunt. Resident # did not have her AV shunt/fistula monitored for bruit and thrill every shift and as needed (prn) as directed by her care plan. This practice affected one (1) of one (1) [MEDICAL TREATMENT] resident in the facility. Resident identifier: #10. Facility census: 102. Findings include: a) Resident #10 Review of the medical record on 10/04/17 at 9:22 a.m. revealed Resident #10 was admitted on [DATE]. Her [DIAGNOSES REDACTED]. She has an AV shunt/fistula for [MEDICAL TREATMENT] access. The care plan contained an intervention initiated on 06/16/17 (typed as written): .Protect shunt sites from injury-check for patency, palpate for thrill, and auscultate for bruit q (every) shift and prn (as needed). Document presence or absence and notify MD if absence . (Bruit is the sound of blood flowing through the AV shunt. Thrill is the vibration of blood going through the arm). Inquired about the location of [MEDICAL TREATMENT] AV shunt assessment documentation on 10/04/17 at 10:31 a.m. from Licensed Practical Nurse (LPN) #131 and Registered Nurse (RN) #112 due to being unable to locate documentation in the medical record. LPN #131 commented, It is documented in the TAR (treatment administration record) I will look in the computer. RN #112 proceeded to print copies of the TAR from Resident #10's admitted to present. Review of the TAR's revealed documentation stating (typed as written): Check fistula right arm q shift for bruit and thrill every shift for patency She stated, The nurses work twelve (12) hour shifts so that is why the assessment is just for Day and Night shift. Review of the TAR's in the presence of RN #112 and LPN #131 revealed blank areas for assessment dates of the following: --06/06/17 on Day shift. --06/22/17 on Day shift. --07/23/17 on Day shift. --09/25/17 on Day shift. LPN #131 and RN #112 verified and agreed there were blank spaces for fistula assessment on the TAR. LPN #131 stated, The blank spaces mean the fistula was not assessed for that shift. After review of the TAR and care plan RN #112 stated, No the care plan was not followed for assessment of the fistula every shift. During an interview on 10/04/17 at 11:57 a.m. the Assitant Director of Nursing (ADON) #121 reported, I will be checking to see why these assessments were not done, there is no excuse.",2020-09-01
575,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2017-10-04,431,E,0,1,TF8J11,"Based on observation and staff interview, the facility failed to store alcoholic beverages in accordance with professional guidelines. An opened 750 milliliter (ml) bottle of Rosso wine labeled with a resident name, an opened 750 ml bottle of Chablis St[NAME]wine labeled with a resident name, an unopened 750 ml bottle of Sauvignon Blanc wine labeled with a resident name, an opened unlabeled 750 ml bottle of Baileys Irish Cream Liqueur (an Irish whiskey and cream based liqueur), two (2) unlabeled unopened 50 ml bottles of[NAME]Beam Devil's Cut 90 proof Bourbon and an unlabeled unopened 4.6 ounce (oz.) box containing twelve (12)[NAME]Beam Kentucky bourbon filled bottle shaped dark chocolates. There was no procedure to mark the remaining amount of liquid/liqueur after administering a dose in the opened bottles and no future plans to include the unopened bottles of liquid/liqueur and the liquor filled chocolates. This was found in one (1) of two (2) medication rooms observed for medication storage. This practice has the potential to affect more than an isolated number of residents. Facility census: 102. Findings include: a) First-floor medication room Observation of the first-floor medication room accompanied by Assistant Director of Nursing (ADON) #93 on 10/02/17 at 12:30 p.m. revealed an opened 750 milliliter (ml) bottle of Rosso wine labeled with a resident name, an opened 750 ml bottle of Chablis St[NAME]wine labeled with a resident name, an unopened 750 ml bottle of Sauvignon Blanc wine labeled with a resident name, an opened unlabeled 750 ml bottle of Baileys Irish Cream Liqueur (an Irish whiskey and cream based liqueur) and two (2) unlabeled unopened 50 ml bottles of[NAME]Beam Devil's Cut 90 proof Bourbon located in an unlocked refrigerator. In addition, an unlabeled unopened 4.6-ounce (oz.) box containing twelve (12)[NAME]Beam Kentucky bourbon filled bottle shaped dark chocolates sitting in a basket on the counter above the unlocked refrigerator. Upon inquiry if this should be stored in a different area and how to determine how much liquor/liquid is left in the bottle, ADON #93 stated, The wine belongs to _________ (name of resident #125) and the[NAME]Beam bottles and chocolate belong to ___________ (name of Resident #60). No there is now way to know if the correct amount is left in the bottle because there is no marking or nothing there to show how much is left because the nurses just write down how much they have given. I guess it is possible that any nurse with a key could come in here and have a drink without anyone ever knowing because no one knows how much is supposed to be left in the bottle. She verified the opened 750 ml bottle of Baileys Irish Cream Liqueur (an Irish whiskey and cream based liqueur), two (2) unopened 50 ml bottles of[NAME]Beam Devil's Cut 90 proof Bourbon and an unopened 4.6-ounce (oz.) box containing twelve (12)[NAME]Beam Kentucky bourbon filled bottle shaped dark chocolates were unlabeled with any resident name. ADON #93 further stated, I will correct this immediately by securing the liquor and chocolates. I will also incorporate a procedure to mark the remaining amount of liquid/liqueur after administering a dose. I did not think about it being considered a controlled substance but they certainly are and should be monitored as such. I just thought it was alright taking the small bottles of whiskey and chocolates out of her room because she had received them as a gift. On 10/02/17 at 12:55 p.m. the Administrator was notified of the previous observation and agreed the wine, liquor, and liqueur should be treated as a substance subject to abuse and/or diversion. She commented that there was not a policy in place for alcoholic beverage storage.",2020-09-01
576,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2017-10-04,441,E,0,1,TF8J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, family interview, staff interview and policy/procedure review, the facility failed to maintain an effective Infection Control Program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. Staff failed to provide/maintain a barrier for a multi dose medication bottle when placed in a resident's room for administration. In addition, staff failed to monitor and enforce isolation precautions with visitors. This practice has the potential to affect more than an isolated number of residents residing in the facility. Resident identifiers: #10 and #160. Facility census: 120. Findings include: a) Medication pass During a medication administration observation on 10/04/17 at 8:15 a.m., Licensed Practical Nurse (LPN) #50 entered Resident #218's room to administer his oral medications and eye drops. LPN #50 placed the eye drop bottle directly on the bedside table without a barrier. LPN #50 helped Resident #218 sit up, administered his oral meds and then his eye drops. LPN #50 washed her hands, retrieved the eye drop bottle from the bedside table and returned the uncleaned bottle directly into the medication cart. Immediately following this observation LPN #50 agreed she had placed the multi dose eye drop bottle directly on the bedside table without a barrier and returned the bottle to the med cart without cleaning it. The Infection Control Nurse #37 acknowledged placing the multi dose eye drop bottle directly on the bedside table and returning it to the medication cart without cleaning/sanitizing is an unsanitary practice during an interview on 10/04/17 at 10:00 a.m. b) Resident #10 On 10/02/17 at 3:05 p.m. observed multiple staff members in the hallway and signage outside of Resident #10's room observed signage located on the door frame stating (typed as written); Family and Visitors STOP! Please report to the nurses' station for instructions before entering the room. Stop Stop Contact Precautions Visitors must report to the Nursing station before entering. ALL HEALTHCARE PERSONNEL AND VISITORS/FAMILY: All Healthcare Personnel and VISITORS/FAMILY: Wash hands before entering and leaving patient room. Wear gowns when entering the room. Wear gloves when entering the room . Upon entering Resident #10's room a visitor was sitting at the bedside without wearing PPE as indicated by the signage upon door frame. The visitor then proceeded to exit the room without performing hand hygiene. During the Stage 1 interview Resident #10 comment the visitor was her daughter. Upon inquiry about contact precautions and PPE, she stated, My daughter doesn't wear that stuff and nobody ever told her anything about wearing it. Just the nurses and aides wear that stuff because they told me I have that C stuff (Clostridium difficile or[DIAGNOSES REDACTED]) that gives you diarrheas. c) Resident #160 On 10/03/17 at 8:15 a.m. observed multiple staff members in the hallway, a visitor sitting at Resident #160's bedside without wearing PPE and signage outside of Resident #160's room observed signage located on the door frame stating (typed as written); Family and Visitors STOP! Please report to the nurses' station for instructions before entering the room. Stop. Stop. Contact Precautions Visitors must report to the Nursing station before entering. ALL HEALTHCARE PERSONNEL AND VISITORS/FAMILY: All Healthcare Personnel and VISITORS/FAMILY: Wash hands before entering and leaving patient room. Wear gowns when entering the room. Wear gloves when entering the room . Inquired of Licensed Practical Nurse (LPN) #87 as to the reason for the signage outside of Resident #160's room. LPN #87 stated, She is on contact precautions because of[DIAGNOSES REDACTED] (C. diff is a highly contagious microorganism which can be spread from person-to-person by touch or by direct contact with contaminated objects and surfaces). Upon further inquiry if everyone is required to wear PPE as per the signage, she replied, Yes everyone is to go by the signs as far as wearing PPE, we have tried to educate the husband on hand washing but no he is not wearing the PPE like he is supposed to according to the sign and our policy. During Resident #160's Stage 1 interview she introduced the male visitor in the room (not wearing PPE including gloves) as her husband. Her husband proceeded to uncover Resident #160 ' s feet to show this surveyor her feet with blackened toes and then proceeded to tuck the sheets around Resident #160 ' s feet and body. Upon inquiry about wearing PPE, Resident #160's husband replied, They told me I could wear it or not it was my decision. Review of the Administrative Policy and Procedure Manual titled Infection Control under the sub-title; Clostridium Difficile (typed as written): .Patient will be placed in transmission based isolation (Contact precautions) . B. Contact Precautions GLOVES AND HANDWASHING .In addition to wearing gloves outlined under STANDARD PRECAUTIONS, wear gloves (clean, nonsterile gloves are adequate) when entering the room . GOWN Wear a clean isolation gown each time you enter the patient ' s room. Remove the gown before leaving the patient ' s environment. After gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other patient or environments. Wash your hands after removing your gown and before leaving the room . Assistant Director of Nursing (ADON) #121 reported during an interview on 10/03/17 at 2:32 p.m., I agree it is the visitors without the required PPE, observed it myself with Resident #10 and #160's visitors and educated them about PPE and infection control procedures. Absolutely contact precautions with isolations requiring PPE applies to all staff and all visitors entering those rooms. I cannot believe they were not wearing the PPE and the staff as many as were in the hallways didn't tell them to put it on.",2020-09-01
577,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2017-10-04,514,D,0,1,TF8J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain complete, accurately documented clinical records. Incomplete and/or blank [MEDICAL TREATMENT] communication forms for one (1) of one (1) [MEDICAL TREATMENT] resident whose chart was reviewed during Stage 2 of the Quality Indicator Survey (QIS). This practice has the potential to affect more than an isolated number of residents. Resident identifiers: #10. Facility census: 102. Findings include: a) Resident #10 Review of the medical record on 10/04/17 at 9:22 a.m. revealed Resident #10 was admitted on [DATE]. Her [DIAGNOSES REDACTED]. She has an AV shunt/fistula for [MEDICAL TREATMENT] access. Review of the [MEDICAL TREATMENT] communication sheets for (MONTH) and (MONTH) (YEAR) revealed multiple blank areas for pre-[MEDICAL TREATMENT] and post [MEDICAL TREATMENT] for weights and vital signs (vitals) for the following specified dates: ---09/26/17 Post [MEDICAL TREATMENT] weight. ---09/23/17--Pre [MEDICAL TREATMENT] weight and vital signs. Post [MEDICAL TREATMENT] weight. ---09/21/17-Pre [MEDICAL TREATMENT] weight and vital signs. Post [MEDICAL TREATMENT] weight. ---09/19/17--Pre-[MEDICAL TREATMENT] blood pressure (BP) and pulse. Post [MEDICAL TREATMENT] weight. ---09/16/17--Pre-[MEDICAL TREATMENT] vitals and post [MEDICAL TREATMENT] weight. ---09/14/17-Pre [MEDICAL TREATMENT] weight and vital signs. Post [MEDICAL TREATMENT] weight. ---09/11/17-Pre [MEDICAL TREATMENT] weight and vital signs. Post [MEDICAL TREATMENT] weight. ---09/09/17-Post [MEDICAL TREATMENT] weight. ---09/07/17-Pre [MEDICAL TREATMENT] weight and vital signs. Post [MEDICAL TREATMENT] weight and vital signs. ---09/05/17--.Pre [MEDICAL TREATMENT] weight and vital signs. Post [MEDICAL TREATMENT] weight and vital signs. ---09/02/17-Pre [MEDICAL TREATMENT] weight and post [MEDICAL TREATMENT] weight. ---08/31/17-Pre [MEDICAL TREATMENT] weight and post [MEDICAL TREATMENT] weight. ---08/27/17--Pre [MEDICAL TREATMENT] weight and vitals. Post [MEDICAL TREATMENT] weights. ---08/24/17--Pre and post [MEDICAL TREATMENT] weights. ---08/22/17-Pre [MEDICAL TREATMENT] weight and vital signs. Post [MEDICAL TREATMENT] weight. ---08/19/17-Pre [MEDICAL TREATMENT] weight and vital signs. Post [MEDICAL TREATMENT] weight. ---0817/17-Pre [MEDICAL TREATMENT] weight and vital signs. Post [MEDICAL TREATMENT] weight. ---08/15/17-Pre [MEDICAL TREATMENT] weight and vital signs. Post [MEDICAL TREATMENT] weight. ---08/12/17-Pre [MEDICAL TREATMENT] weight and vital signs. Post [MEDICAL TREATMENT] weight. --08/05/17-Post [MEDICAL TREATMENT] weight. Registered Nurse (RN) #112 reported during an interview on 10/04/17 at 9:41 a.m., The [MEDICAL TREATMENT] communication sheets are on the hard chart which is how they communicate with us and we review them upon _________(name of Resident #10). They are also considered order sheets because they (the [MEDICAL TREATMENT] center) do not use our order sheets. After review of the [MEDICAL TREATMENT] communication sheets for (MONTH) and September, RN #112 agreed and verified for specified dates there were blank areas for pre [MEDICAL TREATMENT] weights, vitals, post [MEDICAL TREATMENT] weights and vitals. She stated, Yes that would be incomplete medical records. During an interview on 10/04/17 at 11:57 a.m. the Assistant Director of Nursing (ADON) #121 reported, I spoke with the [MEDICAL TREATMENT] center and they have computerized records and the paper is just double charting. But they can not print off the [MEDICAL TREATMENT] records because no one would understand them and they are [MEDICAL TREATMENT] records and not part of the chart. She agreed and verified that the communication sheets for (MONTH) and (MONTH) contain blanks for information and considered part of the medical record. Yes it is considered an incomplete medical record. After review of the contract between the facility and the [MEDICAL TREATMENT] company-titled: Nursing Home [MEDICAL TREATMENT] Transfer Agreement which it states: 2. Center Obligations.(d). In providing [MEDICAL TREATMENT] treatment to Designated Residents, Center shall adhere to the requirements of applicable state and federal law and regulations. ADON #121 stated, I will talk with Administrator about the [MEDICAL TREATMENT] center records and ask her to speak with the [MEDICAL TREATMENT] Center.",2020-09-01
578,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2018-10-18,550,G,0,1,4GQP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident interview, the facility failed to treat residents in a dignified manner by answering call lights timely to prevent incontinence of bladder and/or bowel. This failed practice affected three (Resident #2, #78 and #111) of 21 residents interviewed for dignity. The facility census was 128. Findings included: a) Resident #2 On 10/17/18 at 5:44 PM, the clinical record of Resident #2 was reviewed. The resident had [DIAGNOSES REDACTED]. The care plan, most recently reviewed/revised 07/28/18, documented Resident #2 had a problem related to her self-care deficit and required staff intervention or assistance to remain clean, neat and free of body odors. The quarterly Minimum Data Set (MDS) assessment, dated 09/29/18, documented Resident #21 was cognitively intact; required extensive assistance with bed mobility, transfer and toilet use; and was occasionally incontinent of bladder and always continent of bowel. On 10/15/18 at 09:27 AM, during an interview in her room, Resident #2 was asked if the facility had sufficient staffing to meet the needs of the residents without having to wait a long time. The resident stated she has been forced to be incontinent of bowel and bladder when her call light was not answered in a timely manner. She stated she had to wait for 20 minutes for a nurse to answer her call light. She was asked how she felt when she had to be incontinent because the staff did not answer her call light promptly. The resident stated at the time of the incident, It was embarrassing, demoralizing and aggravating. The resident was asked how many times she had been incontinent while she waited for assistance. She stated she did not know. She stated the incident she referred to had occurred in 07/2018. On 10/17/18 at 6:19 PM, during an interview in the Director Of Nursing's (DON) office, the findings were reviewed with the DON and the administrator. They were asked if the coherent resident's feelings of embarrassment, demoralization and aggravation at having to be incontinent of bowel and bladder would affect her sense of dignity. The administrator stated, Yes. On 10/18/18 at 12:45 PM, during an interview in the dining are on Unit 2 North, Certified Nurse Aide (CNA) #42 was asked if she had ever answered Resident #2's call light and found her to have already been incontinent because the call light was not answered in a timely manner. She stated she recalled the resident had been incontinent while waiting for her call light to be answered at least one time. She stated the incident had occurred this past summer. b) Resident #78 On 10/17/18 at 4:39 PM, the clinical record for Resident #78 was reviewed. The resident had [DIAGNOSES REDACTED]. The care plan, most recently reviewed/revised 07/28/18, documented Resident #78 had a problem related to his self-care deficit and requirement for staff intervention or assistance to remain clean, neat and free of body odors. The quarterly Minimum Data Set (MDS) assessment, dated 09/03/18, documented the resident was cognitively intact. Resident #78 required limited assistance with toilet use; required extensive assistance with bed mobility and transfer; and was occasionally incontinent of bladder and always continent of bowel. On 10/15/18 at 1:40 PM, during an interview in his room, Resident #78 was asked if there was enough staff to meet the needs of the residents without having to wait a long time. He stated he had to wait a long time, about 30 minutes, for his call light to be answered when he needed to use the restroom. He stated he had been incontinent of bowel and bladder a few times with the most recent being last week because staff took too long to answer his call light. He stated at the time of the incident, he felt embarrassed when staff did not respond promptly and he was incontinent. On 10/17/18 at 6:22 PM, during an interview in the DON's office, the findings regarding Resident #78 being incontinent due to waiting on staff to respond to call lights were reviewed with the DON and the administrator. They were asked if the coherent resident's feelings of embarrassment at having to be incontinent of bowel and bladder would affect his sense of dignity. The Administrator stated, Yes. On 10/18/18 at 12:46 PM, during an interview in the hallway on Unit 2 North, CNA #42 was asked if she had ever answered the call light of Resident #78 and found him to have already been incontinent because the call light had not been answered in a timely manner. She stated that had occurred with the resident. She further stated Resident #78 was usually continent of bladder and bowel. The resident had told her he had been incontinent because he had waited so long for his call light to be answered. c) Resident #111 On 10/17/18 at 04:00 PM, the clinical record of Resident #111 was reviewed. She had [DIAGNOSES REDACTED]. The care plan, most recently reviewed/revised on 09/17/18, documented Resident #111 had a problem related to her self-care deficit and requirement for staff intervention or assistance to remain clean, neat and free of body odors. The quarterly/Medicare 14-day Minimum Data Set (MDS) assessment, dated 10/05/18, documented Resident #111 was cognitively intact; required limited assistance with bed mobility and transfer; required extensive assistance with toilet use; and was frequently incontinent of bladder and always continent of bowel. On 10/17/18 at 1:42 PM, during an interview in her room, Resident #111 stated she had been incontinent of both bowel and bladder about 2-3 weeks ago on the day shift because her call light was not answered in a timely manner. She was asked how it made her feel to have to be incontinent of bladder and bowel because her call light had not been answered in a timely manner. She stated she was embarrassed and humiliated at the time of the incident. On 10/17/18 at 6:17 PM, during an interview in the DON's office, the findings were reviewed with the DON and the Administrator. They were asked if the coherent resident's feelings of embarrassment and humiliation at having to be incontinent of bowel and bladder would affect her sense of dignity. The Administrator stated, If that is what she says and she's alert and oriented, we would take that as her feelings.",2020-09-01
579,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2018-10-18,554,D,0,1,4GQP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observations and record review, the facility failed to ensure that a Resident (#26) was provided the opportunity to self administer medications. This affected one out of one sampled resident for self administration of medications. Resident #26 was found with over the counter medications on the overbed table without a physician's orders [REDACTED]. Findings included: a) Resident #26 On 10/15/18 at 11:47 AM, Resident #26 was interviewed in her room. During the initial interview an observation was made of a large bottle of Tums sitting on the resident's overbed table. Resident #26 stated that she always kept the bottle of Tums on the overbed table in case [MEDICAL CONDITION] too bad. Review of the clinical record on 10/16/18 at 2:56 PM revealed an admission history dated 11/21/11. The admission history documented Resident #26 was admitted to the facility with [DIAGNOSES REDACTED]. The quarterly Minimum data set (MDS) assessment, dated 07/30/18, documented that the resident had no memory impairment, no mood disturbances and no behaviors. The plan of care (P[NAME]) for GERD, last updated on 08/09/18, documented an intervention that Resident #26 will take medications as ordered by the physician and to monitor for signs and symptoms of GERD. Further clinica record review revealed that Resident #26 had a physician's orders [REDACTED]. On 10/16/18 at 4:50 PM, Licensed Practical Nurse (LPN) # 31 was interviewed at the 1 west nurse's station. LPN #31 stated that Resident #26 did not have an order to keep medications at bedside, but that her family would bring her in anything she wants. LPN #31 revealed that Resident #26 had [MEDICATION NAME] Migraine and the Tums at her bedside. LPN #31 stated that the facility had previously told Resident #26 that she could not have medications at bedside without an order from a physician., LPN #31 stated that she had reported the medications at bedside to her direct supervisor. On 10/16/18 at 5:24 PM, Resident #26 was interviewed in her room. Resident #26 stated that she bought both the Tums and [MEDICATION NAME] migraine with her own money and no one was going to take it away from her. She stated she often took the Tums after a meal and when she felt the [MEDICATION NAME] wasn't working. Resident #26 stated, I do not care if I'm supposed to have it or not, but I'm keeping it. The Tums were kept out on the overbed table. The [MEDICATION NAME] Migraine bottle and an unopened bottle of Tums were in an unlocked drawer. The resident stated that LPN #31 discussed the importance of the physician being aware of all the medications that she was taking, up to and including, over the counter medications. The resident stated that LPN #31 said that they could even talk to her physician about getting an order and assessment for her to keep the medications at bedside. On 10/17/18 at 9:27 AM, Certified Nursing Assistant (CNA) #11 was interviewed. She stated that she had worked with Resident #26 for five years. CNA #11 stated that when she first saw the bottle of Tums, she reported it to her charge nurse. Since it was still there, she assumed it was allowed. CNA #11 stated that she wouldn't necessarily know if Resident #26 had an order to have medications at bedside or not. On 10/17/18 at 2:14 PM, the nursing home administrator (NHA) was interviewed. The NHA stated that we try to satisfy Resident #26's needs, but sometimes we cave in. Resident #26 will tell us that we're not respecting her resident rights. The NHA was unable to describe a plan to keep the other residents from accessing medications kept at bedside in Resident 26's room. On 10/18/18 at 12:30 PM the policy for self-administration of medications, dated (MONTH) (YEAR), was reviewed. The policy, in part, documented .a physician's orders [REDACTED]. If the interdisciplinary committee grants approval that a resident is able to self administer medications, the nurse manager will notify the maintenance department for the need of supplying a lockable drawer, for the resident's bedside stand, as well as 2 keys for the drawer lock. One key shall be kept in the nursing unit's medication room and the other shall be given to the resident. A self-Medication Administration Record [REDACTED]. The unit nurse shall be responsible for verifying with the resident their self-administration of medication and documenting verification on the resident's self-administration record by placing their initials.",2020-09-01
580,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2018-10-18,558,E,0,1,4GQP11,"Based on resident and staff interviews and observations, the facility failed to accommodate for residents' needs and preferences. Specifically, residents were unable to reach the light switch to turn on or turn off their light above the bed to increase their independence. This affected 10 (Resident #41, #121, #5, #78, #96, #112, #34, #128, #79, and #49) of 10 alert and oriented residents interviewed. The facility census was 128. Findings included: A resident meeting was held on 10/16/18 from 3:10 PM to 4:30 PM. There were 10 alert and oriented residents in the meeting that resided on the second floor. These 10 residents included Resident #41, Resident #121, Resident #5, Resident #78, Resident #96, Resident #112, Resident #34, Resident #128, Resident #79, and Resident #49. All 10 residents indicated they had concerns with their overhead bed lights. The light switches were on the wall behind their beds. Resident #49 said she couldn't turn on or turn off her lights on her own because she couldn't reach the switch. Resident #79 and Resident #41 both said they used something long in their rooms in order to reach the lights. The residents said they had to turn on their call lights, so staff would come in and they could turn on or turn off their lights. Resident #79 was interviewed on 10/18/18 at 11:38 AM. She was lying in her bed. There were two light switches behind her bed. She said they were for the overhead bed light. She reached behind to try to touch the light switches but was unable to reach them. She pulled out a long bath sponge and said that was what she used to reach her lights. She said the remote for the bed had two light bulbs on it, but they did not function. The bed remote was supposed to be used for the overhead bed lights, but it wasn't hooked up in order for them to work. She said some residents liked to read at night or have their lights on prior to them going to sleep at night. They had to press their call light and ask for a staff member to turn off or turn on their lights. Certified Nurse Aide (CNA) #23 was interviewed on 10/18/18 at 1:00 PM. She had just left a resident's room. She said the resident wanted her to turn on her overhead bed light. She said she got called into resident's rooms frequently to turn on or turn off their overhead bed lights. She said the residents that were more independent and wanted to be able to do things on their own complained about not being able to reach the light switches.",2020-09-01
581,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2018-10-18,656,D,0,1,4GQP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure the care plan was implemented for one (Resident #20) of 21 sampled residents whose care plans were reviewed. The facility census was 128. Findings include: On 10/17/18 at 3:03 PM, the clinical record of Resident #20 was reviewed. Resident #20 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 07/23/18, documented the resident was cognitively intact; required extensive assistance with bed mobility, transfer and toilet use. Additionally, the MDS stated Resident #20 was occasionally incontinent of bladder and always continent of bowel. The care plan, most recently reviewed/revised 08/06/18, documented Resident #20 had a problem related to her self-care deficit and requirement for staff intervention or assistance to remain clean, neat and free of body odors. An intervention for the problem included to be sure call light is within reach and encourage to use it for assistance. Respond promptly to all requests for assistance. On 10/17/18 at 8:05 AM, the call light monitor screen at the Unit 2 North nurses' station was observed. The monitor indicated the call light of Resident #20 had been initiated at 7:42.21 AM. The call light monitor indicated the call light was answered at 8:31 AM. The length of time between the initiation of the call light and the answering of the call light was 49 minutes. At 8:37 AM on 10/17/18, Certified Nurse Aide (CNA) #97 was interviewed as she exited the room of Resident #20. She was asked if she knew how long the resident's call light had been on. She stated, About 10 min. She stated she had been in another resident's room getting him ready to go out for the day. She was asked what the resident (#20) needed. CNA #97 stated, the resident needed Off the bed pan. At 8:40 AM on 10/17/18, during an interview in the resident's room, Resident #20 was asked if she had been waiting for assistance. She stated, Yes, she was waiting for assistance off the bedpan. On 10/17/18 at 3:36 PM, in the Minimum Data Set (MDS) coordinator's office, the observations were reviewed with the MDS coordinator. She was asked if the resident's care plan had been followed to respond promptly to all requests for assistance. She stated, No.",2020-09-01
582,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2018-10-18,677,D,0,1,4GQP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview and observation, the facility failed to provide personal grooming and specifically shaving a female resident's chin hair. This affected one (Resident #21) of 21 sampled residents. The facility census was 128. Findings included: a) Resident #21 According to the clinical record, reviewed 10/17/18 at 9:22 AM, Resident #21 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS), dated [DATE], Resident #21 was moderately cognitively impaired, with a Brief Interview of Mental Status (BIMS) score of 11 out of 15. She required supervision to limited assistance with all Activities of Daily Living (ADLs). Resident #21's care plans were reviewed on 10/17/18 at 9:40 AM. A care plan revised on 08/09/18, identified the resident as having a self-care deficit. She required staff intervention or assistance to remain clean, neat and free of body odors. Interventions included providing and assisting with bath or shower, oral care twice a day and as needed, grooming and personal hygiene daily and as needed. Resident #21 was interviewed on 10/15/18 at 4:36 PM. She was observed to have long chin hairs on the right side of her chin. The hairs were approximately three quarters of an inch long. Resident #21 was asked about the hairs. She grabbed them and pulled on them. She said her daughter sometimes pulled them out for her, but she hadn't visited in awhile. She said the staff had never shaved or pulled out her hairs for her. She wasn't aware that she had chin hairs. She said she wished someone had told her that she had hairs on her chin. Resident #21 was observed on 10/16/18 and 10/17/18. She was observed to have long chin hairs on the right side of her chin. The hairs were approximately three quarters of an inch long. Resident #21 was interviewed on 10/18/18 at 8:42 AM. She was asked about her chin hairs. She said she would like them pulled out if the staff wanted to do that. Certified Nurse Aide (CNA) #23 was interviewed on 10/18/18 at 9:04 AM. She said the resident primarily did her ADLs on her own. She said the CNAs encourage and supervise her, but she is able to do her own ADLs. She had not noticed that Resident #21 had long chin hairs. Shaving woman's chins is a part of ADLs and something CNAs would do for residents. If staff notice long chin hairs, then the resident should to be asked about it, and then they would shave the resident if the resident wanted them to. At 9:08 AM, CNA #23 went into Resident #21's room. She verified the resident had long hairs on her chin. She asked the resident if she would like her to shave her chin hairs and the resident said, Yes, if you want to. The Director of Nursing (DON) was interviewed on 10/18/18 at 11:01 AM. She said that CNAs could shave woman's chins if they had long hairs. It depended on the resident and whether they wanted the hairs removed or not. Removing chin hairs was a part of cleaning them. She didn't feel that residents having long chin hairs was an issue. As long as residents were clean, that was what mattered. The Nursing Home Administrator was interviewed on 10/18/18 at 12:50 PM. She said that long chin hairs needed to be addressed with care. CNAs should ask residents whether they wanted their hair removed with their morning routine and daily care. She said it depended on the resident's preference with whether a resident having long chin hairs was an issue or not.",2020-09-01
583,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2018-10-18,725,F,0,1,4GQP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of staffing hours and facility policy, the facility failed to ensure that sufficient nursing staffing was provided to attain and maintain the highest practicable physical, mental and psychosocial well being of each resident. Residents, families and staff expressed concerns that the facility did not have sufficient staff to answer resident call lights in a timely manner and to meet the residents' needs. The facility failed to ensure that [NAME]) residents who required assistance or were dependent upon staff for toilet use were provided assistance in a timely manner. This affected one (Resident #20) who required assistance or was dependent upon staff for toilet use and whose clinical records were reviewed. The facility's Resident Census and Condition (CMS form 672) of residents documented, 107 residents required assistance or were dependent upon staff for toilet use. (See F677) and B.) failed to ensure three residents (Residents #2, #78 and #111) of 21 residents who were interviewed were treated in a dignified manner. The residents were forced to be incontinent when their call lights were not answered in a timely manner. (See F550) This deficient practice had the potential to affect all 128 residents residing in the facility. Findings included: This facility was composed of three floors with five separate units and had a census of 128 on 10/15/18. Complaint allegations were reviewed offsite and onsite in the conference room on 10/15/18 at 8:30 AM. The complaint allegations revealed two separate complaints stating the facility did not have enough staff to meet the residents needs in relation to answering resident call lights. The resident council meeting minutes were reviewed on 10/16/18 at 11:30 AM. There were staffing concerns brought up at the meeting held on 08/21/18. The residents indicated they had to wait for someone to answer their call light around meal times. The residents said the staff worked very hard and the facility needed more staff. There was no indication in the minutes this matter had been resolved. Staffing schedules and assignment sheets were provided by the Administrator and the DON and reviewed for dates 10/14/18 thru 10/20/18 in the conference room on 10/16/18 at 12:00 PM. A resident council meeting took place on 10/16/18 from 03:10 PM to 4:30 PM. There were 10 alert and oriented residents in the meeting that resided on the second floor. All 10 residents indicated they had concerns with staffing. Resident #79 said the facility only had once nurse during the day and night and that was not enough. There was no one available to answer the phone because the nurse was busy. She said there were three or fewer Certified Nurse Aides (CNA) during the day and only one or two at night. All residents indicated they had to wait approximately 30 minutes for their call lights to be answered. Resident #79 and #5 said the worst times, where they had to wait the longest, was during change of shift and meal times. Resident #79 said meal times were the worst because the CNAs were in the dining room assisting residents or passing room trays. It was hard for the CNAs to answer lights during those times. Resident #41 said there was no one in the back hallway to answer the lights during meals. During the hours of 7:00 AM and 10:00 AM was another time when waiting was the worst. During this time, the CNAs were busy with getting all the residents up, showered, and serving breakfast. All 10 of the residents indicated they always received their medications late. Sometimes they were hours late. Resident #78 and Resident #121 both indicated they had had accidents from waiting on staff to assist them to the restroom. Resident #41 said she has had to sit on the bed pan for 40 minutes because the CNAs were busy. Resident #49 said that the CNAs looked exhausted by the end of their shift. An interview with the DON on 10/17/18 at 10:30 AM in her office was conducted. The DON provided and discussed the facility's policy on staffing levels. She stated she was aware the staffing had been Short on some days and stated it was mainly due to the transition to the new building. She stated she was working on a new staffing pattern for the new building. She stated the space of the new building was much larger than the old building which created a challenge with the residents being further away from the nurse's station. She stated with the new building being all private rooms, it was more spacious and spread out. The DON stated many of the residents were used to a smaller area and bunched together where they could easily see the staff up and down the hallways. She stated that was not the case in the new building, which made it appear there were not as much staff working. She stated she needed to fill a charge nurse position and a few CNA positions. At 2:59 PM on 10/17/18, the DON stated, They (the residents) shouldn't have to wait over five minutes. On 10/15/18 at 10:27 AM, Resident #2 was asked if there was enough staff to meet the needs of the residents without having to wait a long time. She stated there was always a shortage of staff. She stated she had to wait for 20 minutes for a nurse to answer her call light. On 10/15/18 at 02:40 PM, Resident #78 was asked if there was enough staff to meet the needs of the residents without having to wait a long time. He stated it was particularly difficult to get assistance right after a meal. He stated staff may still be busy in the dining room and, if resident used a call light in their room, it took a long time to get assistance. He stated nursing staff may be clearing the tables or feeding residents when others in their rooms need assistance. On 10/15/18 at 03:19 PM, Resident #30 was asked if there was enough staff to meet the needs of the residents without having to wait a long time. She stated she doesn't get showers as scheduled. She stated she was scheduled to be showered on Tuesday, Thursday and Saturdays but does not receive them. She stated the certified nurse aides have told her they do not have enough time to give her a shower, so they give her a bed bath. On 10/15/18 at 02:19 PM, Resident #79 was asked if there was enough staff to meet the needs of the residents without having to wait a long time. She stated her medication is often administered late in the mornings and in the evenings. On 10/16/18 at 9:30 AM in an interview with Resident #124 in his room. He stated the facility was great and he had no major complaints, but staffing was a problem. He stated he had been in the facility before and in the old building there were no problems with staffing. He stated the facility does not have enough staff to answer call lights timely. He stated a few of his requests were late due to staffing not being sufficient. He stated, The staff work hard, but they need help. On 10/17/18 at 01:42 PM, Resident #111 was interviewed at her request. She stated she had waited for one hour for her call light to be answered on the day shift on 10/16/18. She stated she needed staff to remove her meal tray from her room and needed staff assistance to help with propping up my feet to get circulation going. 10/15/18 at 12:08 PM in an interview with Resident #87's family member, it was revealed, he stated I know they are shorthanded. He stated Resident #87 needed assistance with toileting. On 10/16/18 at 10:00 AM in an interview with Licensed Practical Nurse (LPN) #76 on the West unit, she stated when there were not enough CNAs working, the nurses must help, and medication pass gets interrupted. She stated some residents require more time with care than others, especially when they receive medications and treatments. CNA #21 was interviewed on 10/17/18 at 9:10 AM. She worked on the first floor. She said recently the facility had three CNAs and one day room aide. Prior to the last week, the facility had two CNAs and one day room aide. She said that she felt it was best when there were three CNAs and a day room aide because residents could be cared for timely and could keep their eye on the residents. LPN #39 was interviewed on 10/17/18 at 5:26 PM. She said that she always takes care of 30 residents. If nothing abnormal happened, then she normally has time to get all her tasks done. It was difficult for her to answer the phone, complete medication pass, speak with doctors, and put physician's orders [REDACTED]. She had to assist the CNAs frequently with answering call lights and assisting residents. She said when they first moved to the new building, they only had two CNAs. They did not have a day room aide. Things were bad when that was all the staff they had. Recently they have had three CNAs including a day room aide. She said when it was only her and two CNAs, she would leave her shift and go home crying because she was so worn out, frustrated, and felt she hadn't spent enough time with her residents. She said that the CNAs would be exhausted as well at the end of their shift. On 10/18/18 at 8:40 AM, LPN #33 was interviewed. She stated that she was happy to come back after her 2-week vacation and see surveyors in the building since the staffing was the best it's been in months. She went on to say that the administration of this building did not take into consideration the size of this new building and before there was 2 licensed nurses for the floor and they had each other as a backup. She stated, Here, you're alone with 30 residents and usually only 2 CNAs and it is not safe. CNA #23 was interviewed on 10/18/18 at 9:08 AM. She said staffing was bad when they only had two CNAs working. She said that three CNAs were better, but it could even be difficult with three. She said they were run ragged sometimes. She said care was provided, but not as good as it could be if there were more staff. She said sometimes showers weren't provided when they were short staffed. Incontinence care wasn't always provided every two hours when they only had two aides. They had had three or four CNAs recently and that was very helpful. 10/18/18 at 1:30 PM an interview with the Administrator was conducted in the conference room. She stated the building was a hybrid assisted living design which created challenges when staffing. She stated the facility was working on a revised staffing model for the new building. A request was made to the Administrator and DON for any grievances or incident reports related to staffing, however, none were provided.",2020-09-01
584,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2018-10-18,761,D,0,1,4GQP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy review, the facility failed to ensure medications were stored in locked medication carts. This affected one (Unit 3) of seven medication carts. The facility census was 128. Findings included: On 10/16/18 from 9:46 AM to 9:51 AM, an unlocked, unattended medication cart was observed setting outside room [ROOM NUMBER]. At 9:51 AM on 10/16/18, Registered Nurse (RN) #92 returned to the medication cart. She was asked if the medication cart was supposed to be left unlocked and unattended. She stated, No, it's not. The facility's Storage of Medications policy and procedure documented: Policy: Drugs and biologicals are stored in a secure and orderly manner .and are accessible only to licensed nurses and pharmacy personnel.",2020-09-01
585,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2018-10-18,812,E,0,1,4GQP11,"Based on observation, interviews and record review, the facility failed to ensure that food was stored, prepared, and served food in accordance with professional standards for food service safety. This had the potential to affect 123 out of 128 residents living in the facility. Findings included: During the initial observation of meal service on 10/15/18 at 12:27 PM the following was observed: 1) Dietary Aide (DA) #114 was observed serving lunch in the first floor, west wing country kitchen. The menu items included a cheese pizza or a hot dog. DA #114 was wearing a pair of disposable gloves. She cut one of the round personal sized pizza's in half and picked it up with her gloved hands to place it on the plate. Wearing the same pair of gloves, DA #114 picked up a can of soup, picked up a soup bowl, opened the can of soup, poured it into a bowl, touched the handle of the microwave oven, place the bowl of soup in the microwave oven, pressed the buttons on the microwave, removed the heated bowl of soup from the microwave and placed a plastic lid on the soup bowl. DA #114 then placed the bowl in the serving area and then went back to the steam table where she picked up a personal sized pizza still wearing the same pair of gloves. While still wearing the same pair of gloves, she took a hot dog bun out of a bag, placed the bun in her left hand and place the hot dog in the bun. DA #114 was interviewed about appropriate times to change gloves and wash her hands. DA #114 stated that she considered serving the meal as one task and that she did not need to change her gloves or wash her hands in between tasks. DA #114 stated that she was taught to change gloves and wash her hands in between tasks. 2) On 10/17/18 at 10:48 AM, food preparation was observed in the kitchen. Cook #127 was observed taking food temperature. She removed a thermometer from a container of liquid and shook off the excess liquid and placed the wet thermometer in the food. When interviewed, Cook #127 stated that the liquid was QUAT sanitizer. Cook #127 was unable to describe the procedure for using the QUAT sanitizer for thermometers.",2020-09-01
586,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2018-10-18,814,D,0,1,4GQP11,"Based on observations and interviews the facility failed to provide proper disposal of garbage. This affected one of one dumpster on the facility grounds. The facility census was 128. Findings included: On 10/17/18 at 10:48 AM an observation was made of one dumpster being used for all the garbage in the facility. The dumpster was located off the loading lock. The dumpster did not have a lid on top and there were bags of garbage both inside the dumpster and around the dumpster on the ground. The area around the dumpster had tied bags of garbage, food waste, Styrofoam cups, plastic cups, disposable gloves and plastic bottles on the ground. On 10/17/18 at 10:53 AM Cook #127 was interviewed. Cook #127 stated that she was aware the dumpster did not have a lid. On 10/17/18 at 2:23 PM the Nursing Home Administrator (NHA) was interviewed. The NHA stated that she did not know why this type dumpster was ordered for the facility. The NHA confirmed that to have proper disposal of garbage a lid was necessary on the dumpster and an area around the dumpster free of garbage.",2020-09-01
587,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2018-10-18,880,D,0,1,4GQP11,"Based on observation, staff interview, and policy review, the facility failed to ensure proper hand hygiene was utilized to administer medications via a feeding tube. This affected one (Resident #86) of one sampled resident observed during medication administration. Additionally, the facility failed to dispose of a contaminated bag of linen in one Resident (#82) of seven resident bathrooms observed during initial sample tour. The facility census was 128. Findings included: 1. On 10/16/18 at 10:56 AM, Licensed Practical Nurse (LPN) #81 was observed as she set up medications for feeding tube administration for Resident #86. Upon entering the resident's room, LPN #81 washed her hands and donned gloves. She turned off the feeding pump and picked up the TV control off the floor and placed it on the bed. Without washing her hands or using hand gel and changing gloves, LPN #81 proceeded to open a clean syringe and disconnect the feeding tube from the tubing. She, inserted the syringe into the feeding tube lumen and administered the medication . At 11:40 AM on 10/16/18, in the hallway outside the room of Resident #86, the observation was reviewed with LPN #81. She was asked if she should have removed her gloves, used hand gel, and donned clean gloves after she handled the TV control from the floor and before she handled the feeding tube and administered the medications. She stated she should have changed her gloves after she handled the TV control from the floor . 2. Observation on 10/16/18 at 10:00 AM during environmental rounds on the West Unit was completed. In Resident #82's room, revealed in the bathroom, a clear plastic bag lying on the floor containing towels, a brief and gloves with bowel contents. Interview with Resident #82 on 10/16/18 at 10:00 AM in his room, revealed he ambulates with his sitting walker and he does utilize his bathroom. Interview with the Certified Nursing Aide (CNA) #55 on 10/16/18 at 10:00 AM in Resident #82's bathroom, revealed when asked about the bag of soiled linen and garbage lying on the Residents bathroom floor, she stated, she should have taken it directly to the soiled utility room. CNA #55 stated, she had forgot about leaving the bag on the floor. When asked why it was important to take it directly to the soiled utility room, she stated because it was Dirty and should not be left on the Resident's bathroom floor where he walked. Review of the facility policy titled, Bed Side Nursing Care, Standards of Nursing Practice, dated revision 04/17 was completed. Under the section Nurse Assistants one of the bullet points states: .maintains a clean, safe environment.",2020-09-01
588,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2019-11-06,550,D,0,1,OS8J11,"Based on observation and interview the facility failed to respect the dignity of residents in a manner that promoted and enhanced quality of life. The facility failed to protect a resident from being exposed and failed to cover catheter bags. The failed practice affected three (3) of 28 residents. Resident identifiers: #20, #15 and #74. Facility census: 140. Findings included: A policy review, titled Code of Ethics/Respect for Patients with revision date of 04/2018 was reviewed. The policy stated, Grooming residents as they wish to be groomed in a manner that prevents exposure and maintains dignity. A policy review, titled Standards of Nursing Practice with revision date of 01/2019 was reviewed. The policy stated, Indwelling Catheter drainage collection bag is to be maintained at level below the bladder, off the floor surface and covered to hide appearance of collection bag contents from general viewing. a) Resident #20 An observation, on 11/05/19 at 7:46 AM, revealed Resident #20 laid in bed with bilateral breasts exposed. The bilateral breasts were visible from the hallway. An interview with Licensed Practical Nurse (LPN) #65, on 11/05/19 at 7:49 AM, confirmed Resident #20 was exposed. LPN #65 stated Oh my goodness. b) Resident #15 An observation, on 11/04/19 at 11:23 AM, revealed Resident #15's catheter bag was not covered. An interview with Certified Nursing Assistant (CNA) #71, on 11/04/19 at 11:42 AM, confirmed the catheter cover was sitting in the window sill not covering the catheter bag. CNA #71 stated, someone must have forgotten to put the cover back on his catheter bag after his morning shower. c) Resident #74 An observation of the 1 North Unit, on 11/05/19 at 9:00 AM, revealed Resident #74 was in bed. The catheter bag was not covered, full of urine, on the floor, and fully visible from the hallway. An interview with Licensed Practical Nurse (LPN) #100, on 11/05/19 at 9:05 AM, revealed catheter bags only have to be covered when residents are in the hallways. An interview with the Administrator, on 11/06/19 at 9:30 AM, revealed catheter drainage bags should always be covered.",2020-09-01
589,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2019-11-06,580,D,0,1,OS8J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and interview, the facility failed to ensure a resident's physician was notified concerning the lack of availability of a physician's orders [REDACTED]. ventilator mask was lost or misplaced. This practice affected one (1) of twenty-eight (28) residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier: 121. Facility census: 140. Findings include: a) Resident #121 A review of the facility's policy titled Bedside Nursing Care. Effective date 05/87 with revisions on 01/19 revealed the following: The physician(s), family, significant other and /or POA will be notified of any unexpected or significant change in a resident's condition in a timely manner. The above are notified when the resident's physical, communicative, psychosocial or functional status changes unexpectedly or substantially; the resident is injured; and there is a need for additional direction (change in or an anticipated or unanticipated delay in treatment) in regard to care of the resident. An interview with Resident #121 (R #121), on 11/04/19 at 2:08 PM, revealed the resident's noninvasive ventilator mask was lost or misplaced. R#121 stated that she was unable to use her noninvasive ventilator last night due to her missing ventilator mask. A review of R #121's physician orders, revealed the order Noninvasive Ventilator Setting: Expiratory Positive Airway Pressure (E-PAP) min pressure five (5), E-PAP max pressure twenty (20) , Tidal Volume 400 milliliters (mL), respiratory rate auto, oxygen concentrator flow rate two (2) Liters at bedtime (hs). A review of R #121's medical record, revealed a nursing note created, 11/04/19 at 10:12 PM, Mask missing. Report to day shift to find out next steps to reorder one. An interview with Licensed Practical Nurse (LPN) #60, on 11/05/19 at 2:25 PM, revealed R #121 still did not have a mask for her noninvasive ventilator. LPN #60 stated that the mask, should arrive today, 11/05/19. During an interview with the with LPN #60 on 11/05/19 at 3:31 PM, the LPN #60 stated that there was no documentation that the physician had been notified of the missing ventilator mask that he could find. During an interview with the administrator, on 11/06/19 at 9:55 AM, the administrator states that they used oxygen via nasal cannula during the night shifts and the physician was not notified. No other information was provided prior to the end of the survey on 11/06/19 at 12:00 PM.",2020-09-01
590,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2019-11-06,583,E,0,1,OS8J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a Nurse Report Sheet, Resident Information Boards, a medication packet, and a Pre-Admission Evaluation was secured in a manner that protected personal, medical, and health information. Personal identifiers including resident's names, room numbers, birth date, medications, medical interventions, allergies [REDACTED]. These were all random observations. This practice affected more than a limited number of residents. Facility census: 140. Findings include: a) Observation Observations of 1 North, 2 West, 2 North, 2 West, and the 300 Halls, on 11/05/19, revealed each unit contained a Resident Information Board at each Nurse's Station. The 300 Hall Resident Information Board could be seen by anyone in the hallway. The other Resident Information Boards could be seen by anyone who walked in the Nurse's Station. 2 North contained an uncovered Nurse Report Sheet on top of a medication cart, the 300 Hall contained an uncovered Pre-Admission Evaluation on the counter of the Nurse's Station, and 1 North contained an empty medication box that was left on top of the medication cart. No staff members were present at the time the Nurse Report Sheet, Pre-Admission Evaluation, and medication box were observed. The Resident Information Boards, Nurse Report Sheet, Pre-Admission Evaluation, and medication box, contained the following resident information: -Names -Room numbers -Birth date -Marital status -Physicians -Medications -Medical interventions -allergies [REDACTED]. -Insurance information b) Interview An interview with the Administrator, on 11/05/19 at 12:35 PM, revealed that no resident information should be seen by anyone who does not need to see it for medical services. The Administrator stated she would have the Resident Information Boards removed immediately and ensure her staff was educated not to leave resident information unsecured.",2020-09-01
591,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2019-11-06,623,E,0,1,OS8J11,"Based on documentation review and interview, the facility failed to provide the ombudsman with the notice of the transfer or discharge of residents. This was evident for more than a limited number of residents who have been discharged . Resident identifier: #114. Facility census: 140. Findings included: a) A review of the facility policy from the Administrative Policy and Procedure Manual had a statement on page 2 which stated a copy of the notice will be sent to the Office of the West Virginia Long Term Care Ombudsman. This policy contained an effective date of (MONTH) 8, 1995 with the latest revision date listed as 4/18. b) Nursing notes of 07/09/19 revealed the resident was found to be very weak and sat on the couch in a day room breathing very heavily. vitals were obtained unable to be determined, residents skin was pale, clammy and the night gown was soaked with sweat. Lung sounds crackle bilaterally . The resident who is normally verbal, was unable to talk was then sent to the hospital. A review of the resident's documentation in the medical record with the social worker, #141 on 11/05/19 at 2:00 p.m. revealed there was no notification to the ombudsman of the resident's discharge. He at the time informed surveyors that he had not been aware that he needed to send any notification of the transfer. The resident would receive the address and phone number of the ombudsman but the ombudsman themselves was not notified when the resident actually left the facility. c) An interview with the administrator, #100 at 2:30 p.m. revealed she was researching if they facility had a policy regarding notification to the ombudsman when some one discharged or transferred. This policy was provided on 11/06/19 at 7:45 am. It had been in effect for some time but had not been adhered to as the policy required.",2020-09-01
592,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2019-11-06,689,E,0,1,OS8J11,"Based on observation and interview, the facility failed to provide an environment free from accident hazards over which it had control. Multiple unsecured shower rooms, hallway cabinets, a nurses station, and the Mail Room, contained shaving razors, scissors, and mail openers. These were random observations. This practice had the potential to affect more than a limited number of residents. Area identifiers: 1 North, 1 West, 2 North, 2 West, 3rd Floor Nurses Station, and 2nd Floor Mail Room. Facility census: 140. Findings include: a) Observations Multiple observations of the 1 North, 1 West, 2 North, 2 West, 3rd Floor Nurses Station, and 2nd Floor Mail Room, on 11/05/19 and 11/06/19, revealed the Shower Rooms, Hallway Storage Cabinets, 2nd Floor Mail Room, and 3rd Floor Nurses Station, were not locked and accessible to anyone. All of these areas were located on or near resident rooms and hallways. These rooms and cabinets each contained the following: -1 North Shower Room-seven (7) shaving razors -1 West Shower Room-nine (9) shaving razors -2 North Hallway Cabinets-six (6) shaving razors -2 West Hallway Cabinets-five (5) shaving razors -2nd Floor Mail Room-two (2) pairs of scissors and two (2) mail openers -3rd Floor Nurse's Station-two (2) pairs of scissors b) Interview An interview with Administrator, on 11/05/19 at 2:55 PM, revealed all razors, scissors, and mail openers should be secured away from all residents. The Administrator stated the facility has three (3) residents who have Dementia or Alzheimer's who wander along with multiple other residents without psychosocial impairment who are able to ambulate throughout the facility. The Administrator stated she would ensure all sharps are locked up immediately.",2020-09-01
593,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2019-11-06,695,D,0,1,OS8J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. The physician's orders [REDACTED]. This practice affected one (1) of six (6) residents reviewed for respiratory care during the Long-Term Care Survey Process (LTCSP). Resident Identifier: #121. Facility Census: 140. Finding included: a) Resident #121 A review of American Association for Respiratory Care Clinical Practice Guideline -Oxygen Therapy in the Home or Alternate Site Health Care Facility -2007 Revision & Update P1063-1067- Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of [MEDICAL CONDITION]. Oxygen is a medical gas and should only be dispensed in accordance with all federal, state, and local laws and regulations. An observation of Resident #121, on 11/04/19 at 2:06 PM, revealed the Resident was receiving oxygen at two and a half (2.5) Liters via nasal cannula (an oxygen delivery device) from an oxygen concentrator. A review of the Resident's physician order, revealed the order Oxygen two (2) Liters, Route: nasal cannula, Frequency: continuous with rest and four (4) Liters continuous with exertion to maintain oxygen saturation ninety-two (92) % or greater with an order date of 09/17/19. A second observation of Resident #121, on 11/05/19 at 2:16 PM, revealed the Resident was receiving oxygen at three (3) Liters via nasal cannula from an oxygen concentrator. An interview with Registered Nurse (RN) #96 on 11/05/19 at 2:20 PM, verified the Resident was receiving oxygen at three (3) Liters. An interview with Licensed Practical Nurse (LPN) #60 on 11/05/19 at 2:25 PM, verified the resident was ordered oxygen at two (2) Liters via nasal cannula with rest. The LPN verified the oxygen level was wrong.",2020-09-01
594,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2019-11-06,732,D,0,1,OS8J11,"Based on observation and interview, the facility failed to post a Daily Nurse Staffing Report, which included, facility name, current date, the total number and the actual hours worked by (Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides) directly responsible for resident care per shift, along with resident census. The 2 North and 1 West Units did not have the Daily Nurse Staffing Report posted at the start of each shift. These were random observations. Facility census: 140. Findings include: a) Observations Observation of the 2 North Unit, on 11/05/19 at 9:05 AM, revealed the Daily Nurse Staffing Report was blank for the 7 AM to 7 PM shift. Observation of the 1 West Unit, on 11/06/19 at 8:05 AM, revealed the Daily Nurse Staffing Report was blank for the 7 AM to 7 PM shift. b) Interview An interview with the Administrator, on 11/06/19 at 8:30 AM, revealed the Daily Nurse Staffing Reports should be completed and posted at the start of each new shift. The Administrator stated the day shift starts at 7 AM.",2020-09-01
595,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2019-11-06,758,D,0,1,OS8J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to document and implement non-pharmacological intervention approaches. The facility did not document non-pharmacological intervention approaches on the care plan or in the medical record. The failed practice affected one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #105. Facility census: 140. Findings included: a) Resident #105 A record review, on 11/05/19 at 11:13 AM, revealed no documentation or implementation of non-pharmacological approaches used for [MEDICAL CONDITION] medications on the care plan or in progress notes of the medical record. An interview with Registered Nurse (RN) #107, on 11/05/19 at 11:50 AM, confirmed no evidence of non-pharmacological interventions documented on the care plan. RN #107 stated, I would expect to see non-pharmacological interventions on the care plan. An interview with Quality Nurse (QN) #186, on 11/05/19 at 3:50 PM, confirmed behavior sheet stated see care plan however no evidence of non-pharmacological intervention approaches were documented on the care plan.",2020-09-01
596,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2019-11-06,761,E,0,1,OS8J11,"**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 in accordance with currently accepted professional principles. A stock medication stored in the 1 North Medication room was expired. This practice had the potential to affect a limited number of residents. Facility census: 140. Findings include: a) Observation An observation of 1 North Unit's Medication Room, on [DATE] at 8:55 AM, revealed the room contained the following item: -One (1) bottle of stock Vitamin D3 with an expiration date of ,[DATE]. b) Interview An interview with Licensed Practical Nurse (LPN) #20, on [DATE] at 8:58 AM, revealed the medication should have been discarded at the end of (MONTH) 2019. The LPN stated stock medications are used for multiple residents. The LPN discarded the medication.",2020-09-01
597,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2019-11-06,880,D,0,1,OS8J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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. Two (2) catheter bags were on the floor and a nurse conducting a dressing change did not provide a barrier for wound supplies nor wash her hands appropriately during the dressing change. These practices affected three (3) of twenty-eight (28) residents reviewed for infection control during the Long Term Care Survey Process (LTCSP). Resident identifiers: #74, #15, and #85. Facility census: 140. Findings include: a) Resident #74 An observation of the 1 North Unit, on 11/05/19 at 9:00 AM, revealed Resident #74 was in bed. The catheter bag was not covered, full of urine, on the floor, and fully visible from the hallway. An interview with Licensed Practical Nurse (LPN) #100, on 11/05/19 at 9:05 AM, revealed catheter bags should never be on the floor. An interview with the Administrator, on 11/06/19 at 9:30 AM, revealed catheter drainage bags should always be off the floor. b) Resident #15 A policy review, titled Standards of Nursing Practice with revision date of 01/2019 was reviewed. The policy stated, Indwelling Catheter drainage collection bag is to be maintained at level below the bladder, off the floor surface and covered to hide appearance of collection bag contents from general viewing. An observation, on 11/04/19 at 11:23 AM, revealed Resident #15's catheter bag hung off the side of the bed touching the floor. The catheter bag was observed folded in half due to contact with floor. Half of the catheter bag hung from the bed and the other half laid on the floor. An interview with Certified Nursing Assistant (CNA) #71, on 11/04/19 at 11:42 AM, confirmed the catheter bag was touching the floor surface. CNA #71 stated that catheter bags touch the floor when a resident's bed is in the lowest position. c) Resident #85 An observation on 11/06/19 at 8:01 AM, of Registered Nurse (RN) #127 providing wound care to Resident #85's pressure ulcer, revealed a breach in infection control practices. RN #127 placed wound care supplies on the over-bed table without providing a clean surface or barrier to work from. RN #127 donned gloves and removed dirty dressing from Resident #85's coccyx. RN #127 cleaned and dried the wound. RN #127 doffed gloves and retrieved a second pair of gloves. RN #127 donned the second pair of gloves without preforming hand hygiene. RN #127 applied santyl ointment and covered area with [MEDICATION NAME] dressing. The RN placed the open ointment on the over-bed table without a barrier. An interview with RN #127, after provision of wound care, revealed RN #127 confirmed that the over-bed table was not cleaned prior to applying wound dressing supplies and that hand hygiene was not preformed after doffing gloves during the wound care dressing change.",2020-09-01
598,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2020-01-15,641,D,0,1,BZFH11,"Based on record review and staff interview, the facility failed to accurately complete section K (nutritional status) of the Minimum Data Set (MDS) assessment for Resident #24. This deficient practice was found for one (1) of five (5) residents reviewed for the care area of nutrition. Resident identifier: #24. Facility census: 44. Findings included: a) Resident #24 On 01/14/20 at 10:30 AM Resident #24's MDS assessment with an Assessment Reference Date (ARD) of 11/21/19 was reviewed. Resident #24's weight on section K of the assessment had been coded as 173 pounds, and significant weight loss over one (1) or six (6) months was coded. A review of Resident #24's weight records during the survey found Resident #24 weighed 171 pounds at the time of the assessment and did not have significant weight loss over one (1) or six (6) months. On 01/14/20 at 3:17 PM the facility's Certified Dietary Manager (CDM) and Registered Dietitian (RD) were interviewed regarding the above discrepancies. The CDM stated that she had used the wrong weight to code the assessment. The RD confirmed the computer system had pulled the wrong comparison weight and therefore had erroneously indicated Resident #24 had significant weight loss over six (6) months. The above information was discussed with the facility's Administrator on 01/14/20 at 4:00 PM, and no further information was provided prior to exit.",2020-09-01
599,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2020-01-15,812,F,0,1,BZFH11,"Based on observation, policy review, and staff interview, found the dietary staff had not ensured sanitary techniques were implemented. Broken egg shells were placed in the carton of unbroken eggs stored in the refrigerator. A wet, stained towel was in the floor on the front right side of the freezer. Additionally, the facility failed to maintain their dry storage area and resident pantry in a safe and sanitary manner. Dented cans were found in the dry storage area, an unlabeled food container was found in the resident pantry refrigerator, and the ice scoop in the resident pantry was stored inside the machine. These deficient practices had the potential to affect more than an isolated number of residents. Facility census: 44. Findings included: a) During the initial tour of the Dietary Department with the Certified Dietary Manager (CDM) on 01/13/20 at 10:20 AM, the following issues were noted and confirmed: - Broken eggs shells were placed in the carton with unbroken eggs and stored in refrigerator ; - a wet, stained(brown/black in color) towel was in the floor on the right side of the freezer. The above findings were discussed with the facility's Administrator on 01/14/20 at 12:32 PM, and no further information was provided prior to exit. b) Follow-up Kitchen and Resident Pantry Tour On 01/14/20 at 11:32 AM a 105 ounce can of mandarin oranges in the dry storage room was found to have a large, creased dent on the side. At 11:34 AM, also in the dry storage room, a 117 ounce can of bean pot baked beans was found to have a deep, v-shaped dent on the top seam and a large, creased dent on the bottom seam. On 01/14/20 at 11:48 AM the facility's Certified Dietary Manager (CDM) confirmed the cans were dented and stated that she would discard them. On 01/14/20 at 11:51 AM an unlabeled food container was found in the refrigerator within the facility's resident pantry. At the time of the finding, the CDM removed the unlabeled container, confirming the container should have had a label if stored in the pantry. On 01/14/20 at 11:54 AM, also in the resident pantry, the ice scoop was observed to be stored inside the ice machine with the ice. At the time of the finding, the CDM confirmed that the scoop should have been stored separately from the ice, and removed the scoop from the machine. The above findings were discussed with the facility's Administrator on 01/14/20 at 12:32 PM, and no further information was provided prior to exit. c) Policy Review During the survey, a review of the facility's policy Nursing Unit Kitchenette Stocking/Safety/Sanitation/Maintenance, last revised on 03/30/17, found that, All unlabeled and dated items will be discarded.",2020-09-01
600,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2020-01-15,880,D,0,1,BZFH11,"Based on observation and staff interview, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infection. Resident identifier: #24. Facility census: 44. Findings included: a) Resident #24 While preparing to give medications to Resident #24, on 01/14/2020 at 9:00 AM Licensed Practical Nurse (LPN)#30 placed a medication cup containing Prosource (a protein supplement) inside of a medication cup containing medications. Both cups were on the top of the med cart without a barrier. LPN #30 also placed an inhaler disk on the over bed table without first placing a barrier. This was brought to the attention of LPN #30 whom agreed a barrier should have been used.",2020-09-01
601,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2019-03-06,641,D,0,1,33PA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete accurate comprehensive assessments related to medications for two (2) of two (2) residents receiving [MEDICATION NAME] (an antiplatelet drug). Facility census: 44. Resident identifier: #18 Findings included: a) Resident (R) #18 Review of the medical record on 03/06/19 at 08:50 AM, revealed R #18 was admitted to the facility in (YEAR). Her daily medications included [MEDICATION NAME] (generic name for [MEDICATION NAME]). The Medication Administration Record [REDACTED]. The record lacked any information indicating R #18 received an anticoagulant. The comprehensive minimum data set (MDS) assessment with an assessment reference date (ARD) of 08/01/19, indicates R #18 received an anticoagulant daily during the seven day look back period under section N0410E. **The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 manual states under the coding instructions for N0410E Anticoagulant .Do not code antiplatelet medications such as aspirin/extended release, [MEDICATION NAME], or [MEDICATION NAME] here. During an interview on 03/06/19 at 9:30 AM, the Registered Nurse Assessment Coordinator (RNAC) #39, confirmed R #18 did not receive anticoagulants and the comprehensive assessment with an ARD of 08/01/19, is coded incorrectly under section N0410E. b) Resident (R#37) A review of the annual minimum data set (MDS), on 03/05/19 at 10:38 AM, with an assessment review date (ARD) of 02/14/19, revealed Section N 'Medications' (N0410) was marked R#37 was taking an anticoagulant. The MDS inaccurately reflected the status of an anticoagulant for Resident #37 due to the resident was taking [MEDICATION NAME] Tablet 75 MG ([MEDICATION NAME] Bisulfate an antiplatelet, not an anticoagulant. Some pertinent [DIAGNOSES REDACTED]. The resident also had a cardiac pacemaker. On 03/05/19 at 02:12 PM, an interview with Licensed Practical Nurse (LPN#35) revealed the resident was taking [MEDICATION NAME] Tablet 75 MG ([MEDICATION NAME] Bisulfate) one time a day due to the resident having had a stroke. Review of orders revealed [MEDICATION NAME] Tablet 75 MG ([MEDICATION NAME] Bisulfate) Give 75 mg by mouth one time a day for other. LPN#35 said she was going to have the record corrected and the order revised to include the [DIAGNOSES REDACTED].",2020-09-01
602,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2019-03-06,656,D,0,1,33PA11,"**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 person-centered care plan. This was found true for one (1) of seventeen (17) care plans reviewed during the investigation process of the survey. R34 had an order for [REDACTED]. Findings included: a) R34 During a medical record review on 03/05/19 for R34 had a physician's orders [REDACTED]. The care plan was not developed to include this intervention. In an interview 03/05/19 at 11:30 AM, with Employee #39, Registered Nurse Assessment Coordinator (RNAC) verified the care plan did not include the physician's orders [REDACTED].",2020-09-01
603,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2019-03-06,657,D,0,1,33PA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to revise R #18's care plan after she refused to wear eye glasses and to update R #4's care plan after the discontinuation of bi-pap (bilevel possitive airway pressure). This was found for two (2) of 17 residents reviewed during the survey. Facility census: 44. Resident identifier: 18 and 4. Findings included: a) Resident (R) #18 During a random observation on 03/03/19, a nurse aide was heard asking R #18 where her glasses were. Additional observations on 03/03/19 and 03/04/19 found R #18 without eye glasses. A review of the medical record on 03/05/19 at 2:30 PM, revealed R #18's [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 01/08/19, is marked yes under section B1200 indicating corrective lenses are used to verify adequate vision when completing section B1000 (the ability to see in adequate light with glasses or other visual appliances). The current care plan with a revision date of 02/04/19, identifies R #18's activities of daily living (ADLS) self-care deficits with a goal to maintain a current level of function. Interventions include (typed as written): .Wears Glasses: Assist/Prompt/Encourage patient to wear glasses and to keep glasses clean and free of debris. Report damage and scratches to Unit Charge Nurse . During an interview on 03/05/19 at 3:45 PM, Registered Nurse Assessment Coordinator (RNAC) #39 reviewed R #18's care plan and acknowledged it was not up to date. She reported R #18 frequently breaks or throws away her glasses. Her son brings in bags of readers to replace the glasses she looses or breaks. b) R4 A review of the medical record for R4 on 03/05/19 revealed the care plan had not been revised for the discontinued use of a bilevel positive airway pressure ([MEDICAL CONDITION]) on 02/11/19. During an interview on 03/05/19 at 3:21 PM with Employee #39 registered nurse assessment coordinator (RNAC) verified the care plan for R4 had not been revised to show the [MEDICAL CONDITION] had been discontinued.",2020-09-01
604,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2019-03-06,684,D,0,1,33PA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and standing orders the facility failed to follow standing orders for bowel protocol for a resident with a [DIAGNOSES REDACTED]. This was true for one (1) of five (5) residents reviewed for 'Unnecessary Medications, [MEDICAL CONDITION] Medications, and Medication Regimen Review'. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #37. Facility census: 44. Findings included: Resident (R#37) Review of records on 03/05/19 at 12:29 PM, revealed some pertinent [DIAGNOSES REDACTED]. Review of the resident's medication regimen revealed R#37 was receiving [MEDICATION NAME] 50 MG (milligram) one (1) tablet by mouth two (2) times a day for pain related to [MEDICAL CONDITION] Arthritis. [MEDICATION NAME] is an opioid pain medication, that can cause opioid induced constipation (OIC). OIC is the most common side effects of opioid use and can last for the length of treatment. The resident was also taking [MEDICATION NAME] 25 MG by mouth one (1) time a day for depression and [MEDICATION NAME] 0.25 mg by mouth one time a day related to Dementia, which both have a side effect of constipation. Another medication the resident was getting was a stool softener, [MEDICATION NAME] Sodium 100 MG capsule two (2) times a day by mouth, for constipation. A review of the annual minimum data set (MDS), on 03/05/19 at 10:38 AM, with an assessment review date (ARD) of 02/14/19, revealed the residents Brief Interview for Mental Status (BIMS) reveals Cognitive status score of 00, indicating Severe Impairment. The resident needs extensive assistance for most activities of daily living, is totally dependent for bathing; and needs supervision for bed mobility, locomotion, and eating. Resident#37 is frequently incontinent of bladder and is continent of bowel. Review of the resident's bowel movement (BM) records for the month of (MONTH) 2019 revealed the resident went greater than three (3) days without a bowel movement. R#37 had a bowel movement on 02/17/19, and no evidence of another until four (4) days later, on 02/21/19. The Physician's standing order for constipation was as follows; if no BM x 3 days check resident's bowel sounds and document. Notify physician if bowel sounds are absent. If positive bowel sounds give milk of magnesium (MOM) 30ml x1, if no results notify physician. The records showed a nurse gave MOM on 02/21/19 the fourth day with results. On 03/05/19 at 03:26 PM an interview with the Unit Charge Nurse, Registered Nurse (RN#16) revealed resident was sent to the hospital 02/01/19 status [REDACTED]. The resident had stopped talking as a result of the stroke but was starting to talk a little now. Review, on 03/06/19 at 08:20 AM, of a neuro consult dated 02/13/19 revealed the resident had a brain infarct (stroke ) on 02/01/19 with lost ability to communicate. On 03/06/19 at 12:35 PM, an interview and review of records with Unit Charge Nurse, Registered Nurse (RN#16) and the Director of Nursing (DON confirmed records showed R#37 had a BM on 02/17/19, with no BMs on 02/18/19, 02/19/19,and 02/20/19. Records showed the laxative MOM was given by the nurse on the fourth day instead of the third day as instructed by the physician. RN#16 and the DON agreed the order was not followed the laxative was not given on the third day.",2020-09-01
605,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2019-03-06,812,E,0,1,33PA11,"Based on observations and staff interview, the facility failed to store food items without the date opened marked in the kitchen and nursing station nourishment area. Also some equipment needed cleaned and there was not step on trash can for proper disposal of hand towels after washing hands. Facility census: 44. Findings included: a) On 03/04/19 03:45 PM conducted tour shortly after entrance at 2:15 p.m the assistant director of dietary . It was found there was no step on trash can at the dish machine area. Another hand sink in the kitchen had a trash receptacle was present but was running over and needed emptied. Containers of vanilla icing, chocolate icing and cream cheese icing has a date of 1/22/19 on the contained. This was identified as the open date. A package of all bran cereal was opened and marked with an open date of 2/22. Drip pans under the range tops contained an accumulation of food debris and needed cleaned. The nursing nourishment kitchen had containers of apple juice, one dated 11/28 and one dated 2/28. Cranberry juice was dated 1/28. These were identified as open dates. There was also a container of mandarin oranges and one of pasta salad which were not labeled nor dated. Staff nursing staff said this was the open date.",2020-09-01
606,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2019-03-06,842,E,0,1,33PA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to maintain medical records on residents that were complete, accurately documented, readily accessible and systematically organized. This was true for four (4) of five (5) residents reviewed for pneumococcal immunization. Identified residents are Resident #29, #7, #36, and #5. Facility census 44. Findings included: a) Resident #29 The following information was provided on 03/05/19 by the DoN. Resident #29 was admitted on [DATE], a review of the medical records that were provided, Titled, Immunization Report. The follow was listed: -Pneumococcal Conjugate (PCV13) given 11/17/17, the consent, Medical Administration Record (MAR), Physicians orders, were not provided. -PPV23 given 11/16/17, this was also written consented. However, the facility could not provide the following: signed consent, MAR, and/or the Physicians orders. Then the DoN provided the following information on 03/06/19. This did not have a title name only that it was an electronic record from the facility prior to the facility updating to a new electronic system. The follow was as follows: -PCV13 was administered on 11/17/17 -PPV23 was administered on 03/30/10, this was received before this resident was admitted into the facility. Per the records. The Information that was provided was conflicting, as to when the PPV23 was given. During an interview on 03/6/19 at 1:40 PM, DoN agreed that the information was conflicting. She stated that when the facility switched to a new computer system the information was entered in wrong. b) Resident #7 Resident #7 was admitted on [DATE], on the document titled, Immunization Report, had the following information: - PPV23 given 11/16/17, and that a signed consent was provided - PVC13 was given on 11/10/17. Later in the day a print out without a titel was provided, with the following information, -PVC12 was administered on 11/10/17. During an interview on 03/06/19 at 1:40 PM, DoN stated that she was able to get access to the older medical records. She also provided a copy of the signed consents dated, 10/04/17 indicating she consented to receive PVC13 and 11/04/16 consenting to receive PPV23. However, she could not provide any farther information asked for (MAR and Physician orders). she agreed that her records were not accurate and/or easily accessible. c) Resident #36 Resident #36 was admitted on [DATE], the following information was provided from the document titled. Immunization Report -PPV23 administered on 11/16/17. -PVC13 administered on 11/17/17 After questioning the DoN about the two-beaning administered so close together the following document without a title was provided the next day. -PCV13 given 11/17/17, the facility could not provide a signed consent, Physician orders [REDACTED]. -PPV23 given12/10/14. d) Resident #5 Resident #5 was admitted on [DATE], the following information was provided from the first medical record provided titled, 'Immunization Report. -PVC13 was administered on 11/10/17. -PPV23 was administered on 11/16/17 with a signed consent. The other report provided later in the day had the following information: -PPV23 was administered 03/14/14 -PVC13 was administered on 01/01/09 However, the facility provided a signed consent for PVC13 dated 10/10/17. During an interview on 03/06/19 at 1:40 PM, DoN stated that this information that was given was all the she can get. It is unclear if this resident received PVC13 on both dates of 01/01/09 and 10/10/17. She agreed this was an inaccurate, incomplete medical record. DoN stated that she has no way to access the records (Medication Administration Records (MAR), Physicians orders, the signed consents to receive the pneumococcal immunizations).",2020-09-01
607,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2019-03-06,880,F,0,1,33PA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to 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 not having a negative air flow pulling the air from the clean laundry room into the soiled laundry room, this had the potential to affect all residents in the facility. There was also a fall mat placed on top of a resident's bed. This was a random opportunity for discovery. Facility census 44. Finding included: a) Laundry Room During an observation and interview on 03/05/19 at 1:19 PM, Maintenance Supervisor #61 was asked why were the door between the soiled and clean sides of the laundry rooms removed? He stated, that they did not have to have them because there was negative air flow. He was asked how the negative pressure was being accomplished without an exhaust fan on the soiled side to pull the air flow from clean to soiled? He responded, the fan is in the other room, but it's not working right now. He was asked to show me the fan, but he stated again that it was in another room that had the door closed. Upon viewing the other room there was not an exhaust fan in that room either. During an interview on 03/06/19 at 9:55 AM, Administrator was informed about the findings in the laundry room. He said, yes see what I have to deal with the Maintenance Supervisor says as long as they have the air conditioner running it provides a positive air pressure. He was informed that it is supposed to a negative air pressure pulling the clean air to the soiled side. c) room [ROOM NUMBER] bed A During a random opportunity for discovery on 03/04/19 at 2:45 PM, it was discovered in room [ROOM NUMBER] bed A had two (2) floor mats placed on top of the resident's bedspread allowing for poor infection control prevention. In an interview with the Center Nurse Executive (CNE) on 03/04/19 at 2:55 pm verified the floor mats on the resident's bed could be an infection control issue. She immediately had staff to remove the floor mats from the resident's bed and have the bedspread changed.",2020-09-01
608,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2017-08-01,272,D,0,1,UXKW11,"**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 conduct an accurate comprehensive assessment for one (1) of twenty-two (22) sample residents. The comprehensive assessment for resident #204 did not accurately reflect the resident's dental status. This practice has the potential to affect more than an isolated number of residents. Resident identifiers: #204 Facility census: 113 Findings include: During stage one (1) of the Quality Indicator Survey (QIS) general observations, on 07/25/17 at 02:51 p.m., and interview with Resident #204 revealed he had missing teeth. Resident #204 acknowledged that he had missing teeth for a long time, even before he ever came to the facility. A review of the medical record, on 07/31/17 at 11:11 a.m., revealed Resident #204 was initially admitted on [DATE]. The resident was cognitively intact and is able to understand and make himself understood, some [DIAGNOSES REDACTED]. A Nursing Assessment, dated 03/06/17, revealed the resident had no missing teeth, which was inaccurate. Review of a nursing readmission assessment dated [DATE], on 07/31/17 at 12:22 p.m., revealed the resident was accurately assessed as having one or more missing teeth and broken teeth. A review of the admission minimum data set (MDS) with the MDS Nurse #169, on 07/31/17 at 2:14 p.m., with an assessment review date (ARD) of 03/13/17, revealed no missing teeth. The MDS Nurse #169 agreed and confirmed the MDS was inaccurate regarding the resident's oral/dental status.",2020-09-01
609,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2017-08-01,309,D,0,1,UXKW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide 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. A medication was not given to the resident as ordered by the physician. This is true for one (1) of one (1) residents reviewed for [MEDICAL TREATMENT] care. This failed practice had the potential to affect a limited number of residents. Resident identifier: #150. Facility census: 113. Findings include: a) Resident #150 Review of records found a physician order [REDACTED]. Beginning on 07/13/17 and continuing to 07/30/17 medical records reveal blood pressures values requiring the [MEDICATION NAME] 0.2 mg as needed physician order [REDACTED]. On 07/31/17 at 2:54 p.m. registered nurse, #14 agreed the physician order [REDACTED].",2020-09-01
614,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2018-10-10,689,G,0,1,8FWH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy review, the facility failed to ensure that one resident (Resident #94) out of two residents reviewed for accidents had an environment free from clutter that resulted in a fall with serious injuries. Resident #94 experienced actual harm from an unavoidable fall with serious injuries requiring admission to the intensive care unit of the hospital and immediate survey. Findings included: a) Resident #94 A chart review was conducted on 10/10/18 at 8:45 AM. Per clinical record review, the Admission Record noted Resident #94, was admitted to the facility on [DATE], with [MEDICAL CONDITION]. A care plan, dated as initiated 02/15/17, identified Resident #94 had the potential for injury from falls and identified the resident sustained [REDACTED]. The goal was to prevent the resident from further falls and noted to keep her room and hallways free from clutter. This goal was initiated on 02/15/17. Another focus area for the care plan for Resident #94 to be placed on a memory care unit due to her confusion and memory loss related to dementia. The date of the identified problem was 02/16/17. The intervention for this issue was to .keep environment free of hazards . This intervention was dated 02/16/18. The quarterly Minimum Data Set (MDS) assessment dated [DATE], Section C for Cognition identified Resident #94 Brief Interview for Mental Status (BIMS) as 0 out of 15, which identified her as being severely cognitively impaired. Under Section G for Functional Status, noted the resident was independent with ambulation with a walker. Per review of the Progress Notes, Resident #94 sustained the following falls: 1: On 11/01/17, the resident was found on the floor in the lounge of the secured unit. There were no injuries noted. The Fall Investigation Form 5-15 noted fall prevention measures were in place, i.e., shoes and socks were on, it was determined the resident was not incontinent, and she was with others. There was no decline in function determined because of this fall. The care plan was updated accordingly. 2: The resident sustained [REDACTED]. An investigation revealed Resident #94 was found on her right side and outside of her room. Staff reported the resident fell , due to another resident's front wheeled walker (FWW) .lightly hit . Resident #94 and the resident slowly fell to the ground. The investigation revealed the resident had fall prevention measures in place. The resident was not injured and there was no decline in function because of this fall. The care plan was not updated after this fall. 3: Resident #94 sustained a fall on 11/23/17. The investigation noted another resident alerted staff the resident fell in the hallway. There were no injuries noted. It was noted the resident attempted to get herself up off the floor at this time. There was no decline in function determined because of this fall. The investigation noted that fall prevention measures were in place. Both the family and the physician were notified of the incident. The care plan was not updated after this fall. 4: Another fall took place on 12/10/17 with Resident #94. The investigation stated the resident sustained [REDACTED]. There were no apparent injuries, but the resident did complain of pain and she was administered pain medication after the incident. The resident did have fall prevention measures in place. The care plan was updated at this time. The updated included to place hipsters (hip brace) on the resident and to removed them during hygiene. 5: Resident #94 sustained a fall on 06/22/18 while attempting to sit in the dining room and missed the chair. The resident hit the back of her head against the wall and sustained a small bump on the back of her head. The resident denied any injuries or pain. The interdisciplinary team met after the fall and determined there was some decline and directed staff to offer her assistance with her seating and common areas. 6: On 08/14/18 the resident had another witnessed fall. Resident #94 fell while in the lounge area and it was noted that she lost her balance. The resident had no injuries and there was no decline in function noted. The care plan was updated at this time. The care plan noted that staff were to frequently reorient the resident to surroundings. The interdisciplinary team met and discussed the resident's fall with therapy and a certified nursing assistant (CNA). It was documented the resident has [MEDICAL CONDITION], difficulty with walking, impaired memory and unsteady gait and history of falls. The resident was noted to have fall prevention measures in place. 7: Resident #94 sustained a fall on 09/04/18. It was noted the resident was ambulating in the hallway with her front wheeled walker (FWW). The resident sustained [REDACTED]. The resident denied pain. Both the family and physician were notified after the incident. The care plan was updated. 8: Resident #94 sustained a fall on 09/07/18. A fall Progress Note with this same date noted the following, .Walking in hallway with FWW and proper footwear on .Resident observed with blood coming from left eye .vital signs taking (sic) at time of fall .Resident does not voice complaints of pain .Resident was observed walking in the hallway, resident tripped over wet floor sign and then over her walker. Resident was observed falling onto her left side ROM (range of motion) good, left eye observed with blood coming from eye. Residents (sic) walker was underneath of resident along with the wet floor sigh (sic), resident had on nonskid socks and resident was not incontinent at the times .Resident was assessed by NP (nurse practitioner) .ordered to send resident to ER (emergency room ) for further eval (evaluation) . The family and the physician were notified of the incident. The hospital discharge records dated 09/10/18 noted Resident #94 was admitted to the hospital on [DATE] and the admission [DIAGNOSES REDACTED]. The hospital records noted the resident was admitted to Intensive Care, and taken to the operating room for a fixation of the orbital region (boney structure surrounding the eye). The resident was readmitted back to the facility on [DATE]. A SBAR (Situation, Background, Assessment and Recommendation) form was completed on 09/12/18. The SBAR noted the resident's fall on 09/07/18 and the resident fell in the hallway and hit the left side of her face. Vitals signs taken at the time of the event were a blood pressure of 136/78, pulse was 64, respirations were 18, and her temperature was 97.1. It was noted that the resident had a functional status change. The SBAR continued by stating, .Resident was observed walking in the hallway, resident tripped over the wet floor sign and then over her walker. Resident was observed falling onto her left side .left eye observed with blood coming from eye . On 10/10/18 at 9:58 AM Certified Nursing Assistant (CNA) #40 was interviewed. CNA #40 confirmed he had worked for the facility for almost a year and primarily on the secured unit. The staff member confirmed Resident #94 was able to ambulate on her own. He said that he was present on the unit the day Resident #94 fell on [DATE]. CNA #40 said that when the resident fell , he was in another room and heard some commotion. He said that there was a wet floor sign (a hard plastic ladder style sign approximately two feet high) on the outside of her doorway which lead into the resident's room. During this interview, it was observed a wooden type of floor covering in the rooms of the residents and the hallway was carpeted. The staff member said he observed the resident on the hallway floor. He said that there are now paper signs posted which state caution wet floor. An interview was conducted with Housekeeper #62 on 10/10/18. She stated that she does not use the upright wet floor signs since the residents will mess with them and specifically stated, Residents will pick them up or use them as weapons. The Licensed Practical Nurse (LPN) #55 was interviewed on 10/10/18 at 10:11 AM. LPN #55 said that he worked the day that Resident #94 injured herself. He stated that the staff were cleaning up after breakfast and CNA #46 saw the resident on the floor. LPN #55 stated he grabbed the vitals machine and saw the resident with blood coming out from her orbital (eye) area. He stated Housekeeper #190 used the upright wet floor signs after she cleaned a room. He said that he did not remember Resident #94 messing with the wet floor sign before the incident. He said the resident did not have the capacity to understand the meaning of the wet floor sign. CNA #46 was interviewed on 10/10/18 at 10:16 AM. She stated that she had worked at the facility for the past [AGE] years and specifically worked on the secured unit for the past five years. CNA #46 said Housekeeper #190 would routinely place the wet floor sign up. CNA said the wet floor sign was on the outside of the resident's room. She stated that she heard some noise and saw Resident #94 fall and said the resident landed on her left side. The staff member said the wet floor sign was a triangle position over the resident's left leg and her walker was beneath her. A telephone interview was conducted with Housekeeper #190 on 10/10/18 at 12:06 PM. She said that she is no longer employed at the facility and confirmed she placed the wet floor sign on the floor on 09/07/18. She stated the facility never informed her that this would possibly be an environmental hazard for residents who wander. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were interviewed on 10/10/18 at 3:46 PM. Both stated that after the incident they made the change to use a sign to post on the doors of the residents on the secured unit. They confirmed there was no prior discussion that the wet floor signs might be an environmental hazard. On 10/10/18 at 4:01 PM, the DON and the Administrator were interviewed and said they had a video in which they had observed the resident seemed to get weak and then she fell . They confirmed they no longer have access to this video. A facility policy entitled Accidents and Supervision dated as implemented 11/27/17, noted the following, .The resident environment remains as free of accident hazards as possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes Identifying hazards(s) and risk(s) .Evaluating and analyzing hazard(s) and risk(s) .Implementing interventions to reduce hazard(s) and risk(s) .Monitoring for effectiveness and modifying when necessary . Resident #94 experienced actual harm from an unavoidable fall with serious injuries requiring admission to the intensive care unit of the hospital and immediate survey. The facility failed to ensure the resident's environment was hazard free.",2020-09-01
615,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2018-10-10,812,F,0,1,8FWH11,"Based on observation and staff interviews, the facility failed to prepare and serve food in accordance with professional standards for food service safety for hand washing, hairnet use and thermometer sanitization. This affected one of two kitchens. Findings included: The main kitchen was observed on 10/10/18 at 10:39 AM. Dietary aide #125 was observed wearing a cap with over 2-3 inches of hair exposed out the back, uncovered. -At 10:56 AM, cook #194 was observed checking food temperatures from the steam table. The thermometer was lying on the counter in front of the steam table. She placed the thermometer into the meatloaf, without sanitizing. When she took the thermometer out of the meatloaf, she wiped the thermometer stem with a wet cloth. She placed the thermometer into the potatoes with the thermometer wet from the cloth. When she took the thermometer out of the potatoes, she wiped the thermometer stem with the wet rag. She then placed the wet thermometer directly into the broccoli. The thermometer was not working correctly, so she replaced this thermometer. She placed the broken thermometer along the wall for storage. The stem cover fell on to the ground. She picked up the cover. She did not wash her hands and then proceeded to check more food temperatures. She used the same process of taking the temperatures with 4-5 more items on the steamtable. -At 11:01 AM, the dietary aide #125 was observed making peanut butter and jelly sandwiches. He was observed with a cap on with over 2-3 inches of hair exposed out the back, uncovered. The main kitchen was observed again on 10/10/18 at 4:36 PM. Cook # 83 was observed taking temperatures on the steam table. He placed a thermometer into the chicken alfredo dish. He went to the hand washing sink and got a dry paper towel. When he took the thermometer out of the chicken alfredo, he wiped the thermometer with the dry paper towel. No sanitizer was used. He placed the thermometer into the pureed chicken alfredo. When he took the thermometer out, he wiped the thermometer stem with a dry paper towel. No sanitizer was used. He placed the thermometer into the broccoli, cauliflower mix. When he took the thermometer out of the food, he wiped the stem with a dry paper towel. No sanitizer was used. He continued this process for the remainder of the food items on the steam table. Review of the Maintaining Sanitary Tray Line policy, dated 11/27/17, revealed wear hair restraints (bonnets, caps, nets, to cover hair) when preparing or handling food. Review of the (YEAR) Food Code by the Food and Drug Administration, pages 48, 54,76 and 83, revealed food employees shall keep their hands and exposed portions of their arms clean .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 .food shall only contact surfaces of: equipment and utensils that are cleaned .and sanitized .food shall be protected from contamination that may result from a factor or a source. The Food Service Director (FSD) #92 and the Registered Dietitian (RD) #191 were interviewed on 10/10/18 at 5:41 PM. They confirmed they did not have a policy on proper thermometer usage. The FSD stated the staff had been trained but there was no policy to refer to. The FSD confirmed that cook #194's wet rag was a sanitized rag with the potential for chemical contamination. They acknowledged the above concerns.",2020-09-01
616,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2019-11-21,641,D,0,1,HSBX11,"**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 one (1) of twenty-seven (27) assessments reviewed. The MDS for Resident #98 did not accurately reflect the resident's [DIAGNOSES REDACTED]. This had the potential to affect more than a limited number of residents. Resident identifier: #98 Facility census: 113 Findings include a) Resident #98 During a medical record review on 11/20/19 for Resident #98, it was discovered the comprehensive MDS with the assessment reference date (ARD) of 11/12/19 did not accurately reflect the [DIAGNOSES REDACTED].#98 was taking [MEDICATION NAME] 20 milligrams (mg) once daily [MEDICAL CONDITION] 11/06/19. In as interview with the MDS Coordinator on 11/20/19 at 2:36 PM verified the [DIAGNOSES REDACTED].",2020-09-01
617,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2019-11-21,684,D,0,1,HSBX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 concerning Foley catheter and oxygen therapy. Physicians orders were incomplete and not clarified by staff for the balloon size of Resident (R#105) Foley catheter and the flow rate of oxygen for R#21. This was true for two (2) of forty-one (41) resident's orders reviewed. Resident identifiers: #105 and#21. Facility census: 113. Findings included: a) Resident (R#105) On 11/19/19 at 03:57 PM review of records revealed the resident had an indwelling Foley catheter due to a [MEDICAL CONDITION] bladder. The resident's Brief Interview for Mental Status (BIMS) score is eight (8) indicating cognitively the resident is moderately impaired. R#105 needs extensive assistance with activities of daily living. Review of the resident's care plan, on 11/20/19 at 12:25 PM, revealed the resident was care planned for a 16 French Foley catheter with a 10cc balloon. Appropriate interventions for the care of the indwelling catheter was noted in the care plan. After review of orders, on 11/20/19 at 12:44 PM, revealed an order that only said 16 French Foley, dated 10/29/19. An interview with the Director of Nurses (DoN), on 11/20/19 at 01:01 PM, revealed the resident had been out of the facility to the hospital in October. The DoN said when the resident returned to the facility it looks like staff forgot to include the catheter's balloon size in the order and they should have. The DoN confirmed it was an incomplete order and should have noted the balloon size. b) Resident #21 During a medical record review on 11/19/19 for Resident #21 revealed the order for oxygen therapy did not include a specified air flow rate for administering oxygen. The order read; (MONTH) initiate oxygen via nasal cannula for shortness of breath or low oxygen saturation less that 90%. Notify the physician. The order had a start date of 11/19/19. In an interview with the Director of Nursing (DON) on 11/20/19 verified the order did specify an air flow rate for which oxygen was to be administered for Resident #21.",2020-09-01
618,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2019-11-21,812,D,0,1,HSBX11,"Based on observations and interviews, the facility failed to use proper sanitary practices when serving and handling foods. This has the potential to affect a limited number of residents who are served from this same central locations. Census: 113. Findings included: a) Observations of the dietary department were conducted shortly after entrance on 11/18/19 with the dietary manager, Employee #45. At this time the following sanitation issued were noted: 1. the drip pan under the range top was found to have an accumulation of food debris and in need of cleaning; 2. the inside of the microwave oven had many food spills on the interior and splashes on the roof which needed to be cleaned; and 3. the dietary staff was noted to handle food and non-food items with the same gloves. This has the potential to lead to cross contamination. The staff member would handle pans, utensils, etc and then touch hamburger buns using the same gloves. These issues were verified with the dietary manager who was present at the time of the observations.",2020-09-01
619,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2019-11-21,880,E,0,1,HSBX11,"Based on observation and staff interview, the facility failed to implement infection control practices and processes designed to prevent the transmission of disease, infection, and/or cross contamination. This was true due to the failure to maintain negative air flow in the laundry. This practice has the potential to affect more than a limited number of residents. Facility census: 113. Findings include: a) Laundry room Inspection of the laundry room on 11/20/19 at 01:52 PM with Housekeeping Supervisor (HK#59) revealed the laundry exhaust fan, that provided the negative airflow in the dirty laundry room, was not running. The Housekeeping Supervisor was not aware how long the fan was not operating. Maintenance was contacted and Maintenance Assistant (MA#71) tried turning the power switch on and off several times and checked electrical breakers but could not get the fan to work. (MA#71) concluded the exhaust fan was broken and a new one would need to be purchased. Both MA#71 and HK#59 voiced understanding of the importance of having negative air flow in the laundry room. HK#59 acknowledged without maintaining a negative air flow in the dirty laundry it caused an infection control problem. MA#71 confirmed without the exhaust fan working there was no negative airflow. MA#71 said a new fan would be purchased and installed.",2020-09-01
620,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,156,E,0,1,4QX611,"Based on observation and staff interview the facility failed to ensure residents had access to information regarding Resident Rights and the Regional Ombudsman contact information. The facility had not displayed the written information regarding Resident Rights and Ombudsman information in an easily accessible manner, as required by this regulation. This had the potential to affect any resident wishing to review resident rights or contact the Ombudsman. Facility census: 158. Findings include: a) On 03/13/17 at 1:05 p.m., it was discovered the Resident Rights poster with the Ombudsman contact information was located on the wall between two (2) sets of sliding doors at the entrance to the facility. This posting is required to fulfill the facility's obligation to adequately display Resident Rights and Ombudsman's contact information. b) During an interview with the Nursing Home Administrator (NHA) on 03/17/17 at 8:32 a.m., it was verified the Resident Rights poster with the Ombudsman contact information was not easily accessible for residents viewing. No additional information was provided prior to exit.",2020-09-01
621,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,157,D,0,1,4QX611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to immediately notify the physician when Resident #79's blood pressure was outside of the established parameters. This failed practice had the potential to affect one (1) of one (1) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #78. Facility census: 158. Findings include: a) Resident #78 Medical record review for Resident #78, on 03/15/17 at 10:00 a.m., found a physician's orders [REDACTED]. Recheck blood pressure in one (1) hour and if systolic blood pressure (SBP) is greater than 160 millimeters of mercury (mmHg - the unit used to measure blood pressures) call physician. Review of the Resident #78's Medication Administration Record [REDACTED]. At 7:00 p.m. on 01/20/17, recheck of blood pressure was 169/61. Further review of Resident #78's medical records found no evidence the physician was notified. On 03/15/17 at 2:00 p.m., a discussion with Director of Nursing (DON) confirmed the blood pressure for Resident #78 was outside of the physician prescribed parameter. She agreed there was no evidence of physician notification. No additional information was provided prior to exit.",2020-09-01
622,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,202,D,0,1,4QX611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, the facility failed to ensure complete and accurate physician/nursing documentation related to the discharge for Resident #225. Specifically, the facility failed to ensure the physician documented why the resident was unable to be cared for at the facility and required immediate discharge. Resident identifier: #225. Facility census: 158. Findings included: a) Resident #225 Review of Resident #225's medical records, on 03/15/17 at 2:15 p.m., found the resident was admitted to the facility on [DATE] at 4:00 p.m. Her admitting [DIAGNOSES REDACTED]. Further review of the medical records found two (2) nursing notes which read: --01/18/17 at 4:00 p.m., Resident arrived from (Hospital's name), resident's son very upset about residents room and the floor she is on (wanted her on the Transitional Care Unit (TCU) and in a private room) son referred to admissions and the Director of Nursing (DON) for resolution. --01/18/17 at 6:30 p.m., per son's request resident sent to (Name of Hospital) for altered mental status. (Doctor's Name) notified. No further documentation could be found in Resident #225's medical records by nurses and/or physician. Interview with the DON and Registered Nurse (RN) #52, on 03/15/17 at 3:30 p.m., found the physician did not documented the event and occurrences leading to the transfer out to the hospital. No No additional information was provided prior to exit.",2020-09-01
623,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,225,D,0,1,4QX611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the reportable allegations and incidents to the proper state entities, staff interview, and resident interview, the facility failed to report an alleged incident of neglect as required by state law for Resident #8. In addition, the facility failed to report an allegation of abuse in a timely manner for Resident #151. This was true for two (2) of three (3) residents reviewed for the care area of abuse. Resident identifiers: #8 and #151. Facility census: 158. Findings include: a) Resident #8 An investigation alleging the resident had numerous vials of [MEDICATION NAME] ([MEDICATION NAME] sulfate and [MEDICATION NAME]) Inhalation Solution stored in her room. Resident #8 was interviewed during Stage 1 of the Quality Indicator Survey at 3:00 p.m. on 03/13/17. She stated her daughter had found many vials of this medication in her room during a visit. The resident said she did not know how the vials got into her room. All she knew was her daughter took them home with her. [MEDICATION NAME] Inhalation Solution is a [MEDICATION NAME][MEDICATION NAME] that relaxes muscles in the airways and increases air flow to the lungs. It is used to treat or prevent [MEDICATION NAME] in people with reversible obstructive airway disease. Review of the resident's current physician's orders [REDACTED]. Further review of the care plan found the following problem: --History of pocketing medications and attempting to hoard in her room. The goal associated with the problem was: --Resident will have no episodes of medication pocketing times 90 days. Interventions included: Crush all crushable medications. Monitor for pocketing of medications and examine mouth cavity to determine ingestion of the medication. The resident was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. A five-day Medicare Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/07/17 found the resident's brief interview for mental status (BIMS) was 13. A score of 13 indicates the resident is cognitively intact. The resident had been deemed to lack capacity to make medical decision by both her physician and a psychiatrist. Her daughter was her medical power of attorney. An interview with the director of nursing (DON), at 8:59 a.m. on 03/15/17, found she had he was aware of the incident. The DON said, She had some [MEDICATION NAME] at her bedside is what I heard. The current DON thought the former DON looked into the incident before she left her employment at the facility. The unit manager, Registered Nurse (RN) #52 was interviewed, at 9:03 a.m. on 03/15/17. When asked if she was aware of vials of [MEDICATION NAME] being in the resident's room, she replied, I just know it (referring to the [MEDICATION NAME]) was found, (name of licensed Practical nurse, #24 reported it to me. RN #52 said she interviewed all of the nurses and reported they poured the [MEDICATION NAME] in the nebulizer when the resident gets a treatment. All staff denied leaving [MEDICATION NAME] in the resident's room. She said the resident's daughter found the vials and took them home with her. RN #53 stated the daughter told her the vials were found in a three (3) tiered cabinet in the resident's room, and she believed LPN #24 also saw the vials. RN #52 said she told the daughter she would probably never have an answer as to how they got in the resident's room. RN #52 reported this incident to the former DON and the resident's physician. She said the physician changed the resident treatment from 4 times a day to PRN (as needed). The dates on some of the vials were from 2014 and (YEAR). RN #52 said she never documented her investigation. A telephone interview with LPN #24, at 10:31 a.m. on 03/15/17, revealed the daughter gave her the vials she found in the resident's room. She said she did not count the vials but estimated there were at least more than 50 of them in a baby wipes container. She said the vials were already out of their packages. LPN #24 did not know how the medication could have been in the resident's room. She said she reported the issue to RN #52. At 12:03 p.m. on 03/15/17, the DON confirmed the facility had no written investigation of the incident reported by the daughter and the allegation had not been reported to the proper State authorities. At 2:41 p.m. on 03/15/17, Social Worker #116, was interviewed. She said she was aware of the situation. She said the daughter called her via the telephone and said she found vials of medication in her mother's room. SW #116 said she told RN #52 and the former DON. SW #116 said she did not document the telephone call nor did she report the incident to any state authorities. SW #116 said she did not investigated the allegation. SW #116 said she did not remember when the incident occurred but thought, It wasn't that long ago. A second, face to face interview with LPN #24, at 11:20 a.m. on 03/16/17, found she believed the daughter reported the incident to her sometime shortly after Christmas. She estimated the timeframe to be within the first two (2) weeks of (MONTH) (YEAR). At 8:22 a.m. on 03/17/17, the resident's physician was interviewed. She said she was aware of the allegation. She said she had been monitoring the resident and had noticed no difference in her condition after she changed the medication to PRN. The physician stated, Her breathing has been stable without the treatments. When asked what could happen to the resident if she used too much of the medication, she replied, It could increase your heart rate. She was unaware of all the details involved in investigating the incident. Surveyor: Hoover, Regina M. b) Resident #151 A review of reportable allegations and incidents was conducted on 03/15/17 at 3:25 p.m. The social worker was interviewed at the time and stated that an issue of alleged abuse by staff had not been reported in a timely manner for Resident #151. A report showed an incident had occurred on 11/09/16 which alleged the resident had been handled roughly by a NA (nurse aide) while providing care. The NA had been impatient with her and pushed her into the side rail of the bed instead of allowing her to assist with her own mobility. Further review indicated the incident had not been reported to appropriate state agencies until 11/14/16. This was a five (5) day delay when instances of alleged abuse should be reported immediately which is 24 hours or less after the allegation occurs. No additional information was provided prior to exit.",2020-09-01
624,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,226,D,0,1,4QX611,"Based on a random opportunity for discovery, record review, and staff interview, the facility failed to implement written policy and procedures to prohibit and prevent abuse. Resident identifier: #59. Facility census: 158. Findings include: a) Resident #59 Review of the medical records for Resident #59's roommate, Resident #162, revealed Resident #162 became frustrated due to Resident #59's yelling out behaviors. On 10/23/16 at 4:23 p.m., a nursing note written by Licensed Practical Nurse (LPN) #54, revealed Resident #59's roommate (Resident #162) stated to the nurse concerning Resident #59, if she didn't stop keeping her awake at night she was going to make her life a nightmare, and went on to tell the nurse she would make the behavior stop however she could. During an interview, on 03/15/17 at 2:58 p.m., LPN #54 explained she did not believe Resident #59 to be in real danger, she monitored both residents throughout the shift and placed the information concerning Resident #162's threat towards Resident #59 on shift report. Medical records revealed no evidence of monitoring the residents. At 10:47 a.m., on 03/15/17 Register Nurse (RN) #52 stated Resident #162 room change occurred on 11/03/16. Record review found no evidence of additional effort to protect Resident #59 from the threat made by Resident #162. Review of the facility's policy and it procedure (Title OPS287) concerning suspected resident to resident abuse section (5.2) reveals, If the suspected abuse is patient-to-patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation. Resident #162 remained the roommate of Resident #59 until 11/03/16 after the threat on 10/23/16. No additional information was provided prior to exit.",2020-09-01
625,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,250,D,0,1,4QX611,"Based on random opportunity for discovery, record review, staff interview and policy review, the facility failed to provide services to attain or maintain the resident highest practicable physical, mental, psychosocial well-being of residents after verbal threats of harm. Resident identifiers: #59 and #162. Facility census: 158. Findings include: a) Resident #59 Review of the medical records for Resident #59's roommate, Resident #162, revealed Resident #162 became frustrated due to Resident #59's yelling out behaviors. On 10/23/16 at 4:23 p.m., a nursing note revealed Resident #59's roommate (Resident #162) stated to the nurse concerning Resident #59, if she didn't stop keeping her awake at night she was going to make her life a nightmare, and went on to tell the nurse she would make the behavior stop however she could. During an interview, on 03/15/17 at 2:58 p.m., Licensed Practical Nurse (LPN) #54 explained she did not believe Resident #59 to be in real danger, she monitored both residents throughout the shift and placed on shift report Resident #162 threatened Resident #59. Medical records revealed no evidence of monitoring the residents. At 10:47 a.m., on 03/15/17 Registered Nurse (RN) #52 stated Resident #162 room change occurred on 11/03/16. Record review found no evidence of additional effort to protect Resident #59 from the threat made by Resident #162. Resident #162 remained the roommate of Resident #59 until 11/03/16 after the threat of harm was made on 10/23/16. b) Resident #162 On 10/23/16 at 4:23 p.m., a nursing note revealed Resident #162 was unsatisfied with her roommate Resident #59, due to Resident #59 yelling out. Resident #162 also made verbal threats to harm Resident #59. At 10:47 a.m. on 03/15/17, Registered Nurse (RN) #52 stated, Resident #162 remained in the room with Resident #59 until 11/03/16. Review of the facility's policy and it procedure (Title OPS287) concerning suspected resident to resident abuse section (5.2) reveals, If the suspected abuse is patient-to-patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation. No additional information was provided prior to exit.",2020-09-01
626,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,253,E,0,1,4QX611,"Based on observation and staff interview, the facility failed to provide services to ensure rooms were in good repair. Five (5) of forty (40) rooms observed during Stage 1 of the Quality Indicator Survey were found to have cosmetic imperfections such as a hole in a wall, deep scrapes on bathroom doors, missing cove base, and a wardrobe with damaged trim. Room identifiers: #201, #303, #314, #320 and #321. Facility census: 158. Findings include: a) Cosmetic imperfections: 1. On 03/13/17 at 2:20 p.m., observation of Room 201 found a hole in the wall behind the bed. 2. On 03/13/17 at 2:29 p.m., observation of [RM #]3 found scrapes on the bathroom door. 3. On 03/13/17 at 1:27 p.m., observation of Room 314 found scrapes on the bathroom door and cove base pulled away from shower base. 4. On 03/13/17 at 1:32 p.m., observation of Room 320 found cove base pulled away from the wall. 5. On 03/13/17 at 1:41 p.m., observation of Room 321 found scrapes on the bathroom door and a wardrobe with damaged trim. b) Interview with Maintenance Supervisor During an interview with the Maintenance Supervisor on 03/16/17 at 2:35 p.m., he verified the hole in wall, scrapes on bathroom doors, missing and damaged cove base and the wardrobe with the damage trim all needed to be repaired. No additional information was provided prior to exit.",2020-09-01
627,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,272,D,0,1,4QX611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the resident's comprehensive Minimum Data Set (MDS) was accurate. The MDS failed to code the resident's use of an antianxiety medication. This was true for one (1) of five (5) resident's reviewed for unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #114. Facility census: 158. Findings include: a) Resident #114 Medical record review on 03/15/17 found the resident was admitted to the facility on [DATE]. The resident was admitted with a physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the most recent admission MDS, with an assessment reference date (ARD) of 02/21/17, found the MDS coded the resident as not receiving [MEDICATION NAME] (an antianxiety medication) within the past seven (7) days. During an interview with Registered Nurse (RN), clinical reimbursement coordinator #130, on 03/15/2017 11:08 a.m., she verified the MDS was incorrect. She said she should have coded the use of [MEDICATION NAME] for one (1) day (02/20/17). No additional information was provided prior to exit.",2020-09-01
628,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,279,D,0,1,4QX611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview and record review, the facility failed to develop a comprehensive care plan for two (2) of eighteen (18) resident's whose care plans were reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident #46 failed to have a care plan developed for the care area of nutritional services and range of motion. Resident #166 did not have a comprehensive care plan developed for the care area of [MEDICAL TREATMENT]. Resident identifiers: #46 and #166. Facility census: 158. Findings include: a) Resident #46 1. Nutritional services The resident was reviewed for the care area of nutrition during Stage 2 of the Quality Indicator Survey (QIS) because the resident has a BMI (body mass index) of less than 22 and was not receiving nutritional supplements. The Resident's current BMI was 18.5. Review of the past three (3) nutritional assessment, completed by the Registered Dietician found the following assessment and documentation: 11/09/16 assessment: --Resident readmitted to facility last month, this is first available weight since readmission, hospital stay may be contributing to with loss noted below. Also noted recent ATB (antibiotic) orders and also oral candidias and ulcer in mouth noted, with meds (medications) per order: likely contributing to decreased intake. Meds include [MEDICATION NAME] may increase appetite, MVI (multivitamin) with minerals. Resident eats in second floor dining room. Likes hot tea with meals; also yogurt with meals. --Noted BMI was less than 19. --Intake is varying at this time, from 25-50% --Diet ordered was Regular/Liberalized diet House supplement BID x thirty days. 01/17/17, assessment: --The registered dietician noted the resident was to have a house supplement 2 times a day. --The intake observation was: -50% on average noted per available ADL (activities of daily living) entries. --The resident was noted to have a nutrition problem. --The interventions were: Regular/Liberalized diet House supplement BID in place. 02/15/17, assessment --Evaluated, continued with House Supplement two times a day. RD (registered dietician) review, weight up 4# this month, desirable. Meds include [MEDICATION NAME] (may increase appetite, MVI with minerals. Resident eats in second floor dining room. Likes hot tea with meals, other preferences noted per tray card. Large portions provided for additional calories. --Resident's intake was recorded as -50% on average intake noted per available ADL entries. Review of the current physician's orders [REDACTED]. There was a physician's orders [REDACTED]. Assigned Licensed Practical Nurse (LPN) #8 was asked if the resident received a supplement at 4:39 p.m. on 03/14/17. After review of the resident's MAR and TAR with this nurse she said, No, she doesn't get anything. Assigned Nurse Aide (NA) #9 said she thinks maybe the resident gets a supplement, once a day. She said she knows the resident likes vanilla shakes. She said she does not record the percentage of the supplement consumed. At 4:44 p.m. on 03/14/17, Cook #97 was interviewed regarding the resident's diet. She said the resident gets large portions of protein, like that would be a piece and 1/2 of meat. When asked about supplements, Cook #97 said the resident does not get a supplement. Observation of breakfast, on 03/15/17 at approximately 8:35 a.m., found the resident did not have extra portions. She had eggs, toast, and 2 pieces of bacon. NA # 44 verified the resident did not have extra portions on her breakfast tray. The Dietary Manager (DM) was interviewed at 4:40 p.m. on 03/15/17. The DM said the resident gets a house supplement two times a day. The DM was asked how he monitors if the resident is consuming the house supplement. He replied, he doesn't do any monitoring, that's the nurse's job. He said, It's nursing responsible to relay the message to me. When asked about the care plan, he replied, That is for the nursing staff, I don't look at that either. At 4:56 p.m. on 03/15/17, the Director of Nursing (DON) confirmed the percentages of supplement consumed by resident's are to be on the medication administration record. She confirmed Resident #46's percentages had not been recorded because the Resident did not have an order for [REDACTED]. Observation of the evening meal, at 5:30 p.m. on 3/15/17, found the resident received one (1) piece of fish, green beans, potatoes, a roll and dessert. Nurse Aides #62 and #9 verified the resident did not have large portions of food. Her food was the same size as the other resident's eating in the second floor dining room. The Speech Therapist #171 was also in the dining room feeding another resident. She did not believe the resident received extra portions on her tray. The resident did not receive yogurt with her meal as suggested in the 11/09/16 dietary assessment. An interview with Resident #46, at 5:30 p.m. on 03/15/17, found she said she didn't always like the food served. She was aware she could have a substitute but she probably wouldn't eat that either. She said, I just don't have an appetite, I wouldn't eat anything anyway. She said sometimes she get a shake that comes in a carton, like milk. She said she likes those and will drink them when she gets one. At 8:50 a.m. on 08/16/17, the Registered Dietician (RD) was interviewed. She says she monitors the effectiveness of her interventions by, I just ask the staff. This surveyor explained the staff appear confused as to if the resident even receives a house supplement, and there is no recording of the percentages of the house supplement the resident consumed. This surveyor asked the RD how a large portion of food would be effective when the resident was only eating less than 50% of her meals. She had no immediate answer for this question. Review of the current care plan, revised on 09/07/16 found the current problem: --(Name of resident) has a BMI less than 19. The goal associated with this problem was: --(Name of resident) will have no significant weight changes through next review. Approaches included: --Provide diet as ordered The current care plan was discussed with the Clinical Reimbursement Coordinator #100, at 2:30 p.m. on 03/16/17. The resident's care plan was not individualized with her current physician's orders [REDACTED]. An intervention to provide diet as ordered could be an approach for any resident who receives nutrition from the kitchen. 2. Range of motion Observation of Resident #46, on 03/13/17 at 1:57 p.m., found the resident said she was unable to open her left and right hand. Further observation found the resident had three (3) hand splints lying on her bedside night stand. The resident said she likes to wear them at night times. Interview with the assigned Licensed Practical Nurse (LPN) #24, at 1:22 p.m. on 03/14/17, found she was identified as having contractures of both hands. Review of the care plan found the problem: --Resident exhibits alteration in functional mobility related to decrease ROM (range of motion) to bilateral lower extremities and bilateral hands (contractures). The goal was: --Resident will have no increase in contractures x 90 days. Approaches included: --Splint type: Resident to wear bilateral lower leg brace while out of bed for support from weakness due to long term debility. Review of the most recent, quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/17/17, found the resident was coded as having no contractures. Review of the physician's orders [REDACTED]. At 5:00 p.m. 03/14/17, the assigned Nurse Aide (NA) #9 said the resident has never had a leg brace since she has worked here for the past two (2) years. NA #9 said the resident does wear hand splints at nights. During an interview with the assigned Licensed Practical Nurse (LPN) #8, at 1:22 p.m. on 03/14/17, she said the resident never had any leg braces. At 5:04 p.m. on 03/14/17, this surveyor and NA #9 looked in the resident's room and found no evidence of any leg braces. At 5:10 p.m. on 03/14/17, the resident said she did not have any leg braces. At 5:08 p.m. on 03/14/17, the Certified Occupational Therapy Assistant (COTA), #166 and the Director of Rehabilitation, Physical Therapist (PT) #162 were interviewed and asked if the resident needed to have hand splints or leg braces. PT #162 provided documentation the resident had been seen by therapy and hand splints were ordered in (MONTH) of (YEAR). She knew nothing about the leg braces. PT #166 was asked if the resident had contractures of her hands. She stated she would look at her tomorrow and would let me know. At 8:15 a.m. on 03/15/17, NA #27 said the resident was wearing both hand splints this morning when she arrived. She assisted the resident with getting up and getting dressed and she removed the hand splints. She described the splints as being the palm protectors on the resident's night stand. At 8:58 a.m. on 03/16/17, Occupational Therapist (OT) #169 said she had looked at the resident and did not feel she had a contracture. She said the resident opened her right hand and opened the left hand about half way She said the resident has [MEDICAL CONDITION] arthritis. She said, It looks like a contracture but she can open it halfway on the left side. At 10:00 p.m. on 03/16/17, the Director of Nursing (DON) said she found the physician's orders [REDACTED]. On 10/09/15, the order was discontinued and a new order written for a right resting hand splint to be worn from 6:00 p.m. - 8:00 p.m. with range of motion prior to application. The order for the left palm protector to be worn from 6:00 p.m. to morning, remained as written on 08/31/15. The DON said she never found any orders to discontinue the resting hand splint or the palm protector. The DON was advised the staff showed this surveyor two palm protectors being applied to both hands when the resident goes to bed and removed when she gets up in the morning. The DON said she would have therapy evaluate the resident again. At 3:20 p.m. on 3/16/17, the OT #169 said she evaluated the resident and she needs the hand splints. At 2:17 p.m. on 03/16/17, the Clinical Reimbursement Coordinator was interviewed regarding the care plan. The resident had no leg braces and is wearing hand splints without an order. The care plan says the resident has contractures, the MDS says she does not. He said he would look at the care plan and address the issues. b) Resident #166 A review of Resident #166's medical record, completed on 03/16/17 at 12:30 p.m., revealed Resident #166 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #166's care plan was reviewed. It did not address her ongoing [MEDICAL TREATMENT] treatment and care/services need for the correlation of care with the outside [MEDICAL TREATMENT] provider. The Director of Nursing, during an interview on 03/16/17 at 3:00 p.m., stated she did not see Resident #166's [MEDICAL TREATMENT] care/services addressed on her comprehensive care plan. No additional information was provided prior to exit.",2020-09-01
629,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,280,D,0,1,4QX611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise three (3) of eighteen (18) resident care plans when the residents changed status for behaviors, restorative services, and [MEDICAL TREATMENT]. Resident identifiers: #59, #31, and #183. Facility census 158. Findings include: a) Resident #59 Review of Resident #59's nursing notes revealed documented behaviors of yelling out with mental status changes on 10/23/16, 11/10/16, and 2/25/17. The behavior of yelling out and the mental status change of Resident #59 disrupted her roommate to the point Resident #59's roommate requested a room change. Review of Resident #59's care plan with a revision date of 03/15/17 revealed no evidence of the resident having behaviors of yelling out with mental status change. On 03/16/17 at 2:12 p.m., Registered Nurse #100 agreed the care plan should have included at least a focus update. b) Resident #31 A review of the care plan for this resident on 03/14/17 in the afternoon revealed the resident had interventions in the care plan for the use of 1-2 pound dowel rod do the following exercises in sets of three (3) for ten (10) repetitions/sets, right biceps curls, right shoulder abduction and adduction and left wrist extension/flexion. This had an initiation date of 12/15/16. It was related to the problem of loss of range of motion in upper extremities due to functional deterioration. Interview with rehab staff, on 03/17/17 at 8:20 a.m., revealed the resident no longer receives this treatment intervention. Most of these orders are for six (6) weeks and that timeframe would have been over by now and no new orders were written. The resident has experienced slight decline in her abilities due to age and declining condition. The care plan had not be revised to reflect these services were no longer being implemented. c) Resident #183 On 03/15/17, a review of the medical record indicated Resident #183's current physician's orders [REDACTED]. Further review showed a progress note for 01/11/17 indicating the resident's [MEDICAL TREATMENT] catheter had been removed on 12/13/16. The current care plan had not been revised to remove the intervention to maintain smooth catheter clamps at the bedside (and on resident when out of bed) in case of breakage or excessive bleeding from catheter. An interview with Clinical Reimbursement Coordinator #100, on 03/15/17 at 10:45 a.m., verified the intervention to maintain smooth catheter clamps at the bedside (and on resident when out of bed) in case of breakage or excessive bleeding from the catheter should have been removed since Resident #183 had his [MEDICAL TREATMENT] catheter removed on 12/13/16, and no longer required the use of smooth blue clamps. No additional information was provided prior to exit.",2020-09-01
630,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,282,D,0,1,4QX611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observation and staff interviews, the facility failed to implement the care plans for two (2) of eighteen (18) Stage 2 sample residents. The facility did not implement Resident 124's care plan related to poor safety awareness and [MEDICAL CONDITION]. They also failed to implement Resident 114's care plan regarding behavior monitoring for [MEDICAL CONDITION] medications. Resident identifiers: #124 and #114. Facility census: 158. Findings include: a) Resident #124 A review of the medical record on 03/14/17 revealed the care plan interventions to wear knee high compression stockings in the morning and take them off at bedtime due to bilateral leg [MEDICAL CONDITION], hipsters to be worn at all times due to risk of falls and Derma sleeves to bilateral upper extremities to be worn at all times for bruising/skin tears had not been implemented. A physician's orders [REDACTED]. --Knee high compression stockings in the morning and take them off at bedtime was written on 12/30/16; --Hipsters at all times due to history of falls was written on 12/30/16; and --Bilateral derma sleeves for bruising/skin tears to be worn at a times was written on 05/20/16. An observation of Resident #124, on 03/15/17 at 3:17 p.m., revealed the resident had no knee high compression stockings on, no hipsters applied to hips and no bilateral Derma sleeves applied to her arms. On 03/15/17 at 3:25 p.m., Registered Nurse (RN) #34 verified Resident #124 did not have on compression stockings, hipsters or bilateral Derma leaves. b) Resident #114 Record review found the resident was admitted to the facility on [DATE]. admitting [DIAGNOSES REDACTED]. The resident was prescribed [MEDICATION NAME] 0.5 milligrams, 1/2 tablet (0.25 milligrams) twice a day, as needed for a [DIAGNOSES REDACTED]. The medication, [MEDICATION NAME] was administered on 02/20/17, 02/24/17 and 02/27/17 according to the Resident's MAR. Review of the current care plan found the following problem, created on 02/23/17: --Resident is at risk for complications related to the administration of [MEDICAL CONDITION] medications. The goal associated with the problem is: --Resident will have the smallest most effective dose without side effects x 90 days. Interventions included: --Complete behavior monitoring flow sheet The unit charge Registered Nurse (RN) #52 verified, on 03/15/17 at 10:54 a.m., she was unable to find documentation of the behaviors the resident exhibited to warrant the use of [MEDICATION NAME] and was unable to find documentation of any non-pharmacological interventions implemented before given the medication. The resident's record contained no behavior monitoring sheets. At 10:54 a.m. on 03/15/17, the DON was made aware of the above information. She was unable to provide any further documentation of the behaviors exhibited to warrant the use of [MEDICATION NAME] and unable to provide documentation of the non-pharmacological interventions implemented before giving the medication. The DON verified the facility had not followed the care plan as there was no behavior monitoring flow sheet for (MONTH) (YEAR). The PRN medication [MEDICATION NAME], was not administered in (MONTH) (YEAR). No additional information was provided prior to exit. b) Resident #114 Record review found the resident was admitted to the facility on [DATE]. admitting [DIAGNOSES REDACTED]. The resident was prescribed [MEDICATION NAME] 0.5 milligrams, 1/2 tablet (0.25 milligrams) twice a day, as needed for a [DIAGNOSES REDACTED]. The medication, [MEDICATION NAME] was administered on 02/20/17, 02/24/17 and 02/27/17 according to the Resident's MAR. Review of the current care plan found the following problem, created on 02/23/17: --Resident is at risk for complications related to the administration of [MEDICAL CONDITION] medications. The goal associated with the problem is: --Resident will have the smallest most effective dose without side effects x 90 days. Interventions included: --Complete behavior monitoring flow sheet The unit charge Registered Nurse (RN) #52 verified, on 03/15/17 at 10:54 a.m., she was unable to find documentation of the behaviors the resident exhibited to warrant the use of [MEDICATION NAME] and was unable to find documentation of any non-pharmacological interventions implemented before given the medication. The resident's record contained no behavior monitoring sheets. At 10:54 a.m. on 03/15/17, the DON was made aware of the above information. She was unable to provide any further documentation of the behaviors exhibited to warrant the use of [MEDICATION NAME] and unable to provide documentation of the non-pharmacological interventions implemented before giving the medication. The DON verified the facility had not followed the care plan as there was no behavior monitoring flow sheet for (MONTH) (YEAR). The PRN medication [MEDICATION NAME], was not administered in (MONTH) (YEAR). No additional information was provided prior to exit.",2020-09-01
631,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,309,E,0,1,4QX611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record review, the facility failed to provide necessary care and services to five (5) of eighteen (18) Stage 2 sampled residents in order for the residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Resident #166's care plan was not correlated with the [MEDICAL TREATMENT] center. The facility failed to follow physician orders [REDACTED]. The facility failed to obtain vital signs as directed by the physician's orders [REDACTED]. Resident #59 did not have the bowel protocol initiated when no bowel movement was noted for over three (3) days as directed by facility's protocol. The facility failed to obtain glucose checks as directed by a physician order [REDACTED]. Findings include: a) Resident #166 Medical record review found the resident received [MEDICAL TREATMENT] via a perma-catheter in the right [MEDICATION NAME] (relating to, being, or inserted into a part such as an artery, vein, or nerve located under the clavicle) three (3) days a week, on Mondays, Wednesday and Fridays, at an offsite [MEDICAL TREATMENT] center. The resident was admitted , on 09/20/16, and received [MEDICAL TREATMENT] on 09/21/16. The medical record contained no copies of a [MEDICAL TREATMENT] communication record, shared by the facility and the [MEDICAL TREATMENT] center. The resident was in the hospital from 09/21/16 to 09/24/16. The resident received [MEDICAL TREATMENT] on 09/26/16, 09/28/16, 09/30/16, 10/03/16, 10/05/16, 10/07/16, 10/10/16, 10/12/16, 10/14/16, 10/17/16, 10/19/16, 10/21/16, and 10/24/16. The medical record contained incomplete [MEDICAL TREATMENT] communication records for these dates. On 10/26/16 and 10/27/16, Resident #166 received [MEDICAL TREATMENT]. The medical record contained no [MEDICAL TREATMENT] communication record for these treatment days. The top part of the communication form is completed by the facility to include the resident's vital signs before the resident left the facility for [MEDICAL TREATMENT], an examination of the access site and any significant changes since last [MEDICAL TREATMENT] treatment. The middle part of the communication form is completed by the [MEDICAL TREATMENT] center to include obtained vital signs, completed lab work, medications given, intake and output, monitoring the access site for location, the condition of the dressing, ports, pain and any other pertinent information. The bottom part of the communication form is completed by the facility to include a narrative note upon arrival to the facility. Neither the facility, nor the [MEDICAL TREATMENT] center consistently recorded the resident's information pre and post [MEDICAL TREATMENT] treatments on the communication form. The medical record or [MEDICAL TREATMENT] communication form contained no information regarding laboratory values obtained by the [MEDICAL TREATMENT] center. Review of the resident's current care plan, on 03/16/17 at 11:50 a.m., found a care plan initiated on 10/31/16, which contained no goals or interventions concerning [MEDICAL CONDITION] requiring [MEDICAL TREATMENT]. Review of the facility's policy for [MEDICAL TREATMENT] services found the purpose of the policy was, To provide continuation of necessary care and services to those residents receiving [MEDICAL TREATMENT] from a community based [MEDICAL TREATMENT] center. It is the facility responsibility to develop a plan of care for the resident that includes a means of communication between the resident, the center and the facility staff. The policy also contained the following procedures, The facility staff will complete the [MEDICAL TREATMENT] Resident Communication Report to include the information required by the [MEDICAL TREATMENT] center prior to the resident leaving for treatment. The communication form will provide a means of useful communication between the facility and [MEDICAL TREATMENT] center. The resident care plan includes care of the shunt/fistula, including complications, i.e. bleeding infections, etc., nutritional needs, emotional and social well -being, management of [MEDICAL CONDITION] and monitoring aspects will be reviewed per the facility policy for care plan review and on as needed basis. The [MEDICAL TREATMENT] Resident Communication Report will be completed by the licensed nurse prior to the resident transfer. Upon return from the [MEDICAL TREATMENT] center, the resident will be evaluated by the licensed nurse including vital signs, shunt/fistula observation and the results of the evaluation will be documented in the medical record . There needs to be staff education on [MEDICAL CONDITION] and [MEDICAL TREATMENT] complications, documentation, care planning and management. Licensed staff needs to know what to do in case of an emergency. On 03/17/17 at 10:30 a.m., during an interview with the Director of Nursing (DON), she agreed the [MEDICAL TREATMENT] center should supply the facility with pre and post weights. She said she did not know what laboratory values the [MEDICAL TREATMENT] center should obtain. She also agreed there should be better communication between the facility and the [MEDICAL TREATMENT] center. The DON also agreed the resident's care plan did not include goals or interventions concerning [MEDICAL CONDITION] requiring [MEDICAL TREATMENT]. b) Resident #78 A review of Resident #78's medical record, at 1:34 p.m. on 03/16/17, found a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. After 02/01/17, Resident #78 only received [MEDICATION NAME] every six (6) hours as needed. No further physician orders [REDACTED]. An interview with DON, at 2:00 p.m. on 03/17/17, confirmed Resident #78 only received the [MEDICATION NAME] every (6) hours around the clock until 02/01/17. She stated, It looks like it was not transcribed on the (MONTH) (YEAR) MAR indicated [REDACTED]. c) Resident #134 1. Vital Signs Review of Resident #134's records revealed a physician order [REDACTED]. Review of the documentation of vital signs beginning 09/06/16 and ending on 03/12/17 revealed failure to complete vital signs as ordered on six separate weeks. On 03/17/17 at 12:00 p.m., the Director of Nursing (DON) stated there is no evidence to confirm the vital signs were completed every week as ordered by the physician. 2. Pain Management Review of the facility pain management policy revealed a practice standard requiring at a minimum of daily, patients will be evaluated for the presence of pain by making an inquiry of patient or by observing for signs of pain and will complete documentation of the pain monitor on the Medication Administration Record [REDACTED] Review of Resident #134's MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED] --Five (5) of thirty-one (31) opportunities during the month of (MONTH) (YEAR) --Eight (8) of 31 opportunities during the month of (MONTH) (YEAR) --Seven (7) of twenty-eight (28) opportunities during the month of (MONTH) (YEAR) --Nine (9) of sixteen (16) opportunities during the month of (MONTH) (YEAR) On 03/17/17 at 10:10 a.m., the Director of Nursing verified Resident #134's pain monitoring results had not been documented according to the facility's standing physician orders. d) Resident #59 Review of Resident #59's bowel movement documentation revealed no bowel movement from 12/22/16 to 01/02/17. On 03/17/17 at 11:25 a.m., Registered Nurse #52 agreed the facility bowel protocol had not been initiated to prevent constipation of the resident. Record review revealed Resident #59 did not have a documented bowel movement for twelve (12) days. e) Resident #124 A review of the medical record for Resident #124, on 03/17/17 at 11:25 a.m., revealed the Medication Administration Record [REDACTED] --01/10/17 - Lunch --01/20/17 - Dinner --01/27/17 - Lunch --02/08/17 - Dinner Also reviewed the physician's orders [REDACTED]. An interview with the Director of Nursing, on 03/16/17 at 10:35 a.m., verified no blood sugar were recorded on 01/10/17, 01/20/17, 01/27/17 and 02/08/17 and the physician's orders [REDACTED]. No additional information was provided prior to exit.",2020-09-01
632,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,318,D,0,1,4QX611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, and record review, the facility failed to recognize, a resident with a limited range of motion (ROM), was incorrectly assessed to determine the services needed. This was true for one (1) of three (3) residents reviewed for the care area of range of motion during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #46. Census: 158. a) Resident #46 Observation of Resident #46, on 03/13/17 at 1:57 p.m., found the resident said she was unable to open her left and right hand. Further observation found the resident had three (3) hand splints lying on her bedside night stand. The resident said she likes to wear them at night times. Interview with the assigned Licensed Practical Nurse (LPN) #24, at 1:22 p.m. on 03/14/17, found she was identified as having contractures of both hands. Review of the care plan found the problem: --Resident exhibits alteration in functional mobility related to decrease ROM (range of motion) to bilateral lower extremities and bilateral hands (contractures). The goal was: --Resident will have no increase in contractures x 90 days. Approaches included: --Splint type: Resident to wear bilateral lower leg brace while out of bed for support from weakness due to long term debility. Review of the most recent, quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/17/17, found the resident was coded as having no contractures. Review of the physician's orders [REDACTED]. At 5:00 p.m. 03/14/17, the assigned Nurse Aide (NA) #9 said the resident has never had a leg brace since she has worked here for the past two (2) years. NA #9 said the resident does wear hand splints at nights. During an interview with the assigned Licensed Practical Nurse (LPN) #8, at 1:22 p.m. on 03/14/17, she said the resident never had any leg braces. At 5:04 p.m. on 03/14/17, this surveyor and NA #9 looked in the resident's room and found no evidence of any leg braces. At 5:10 p.m. on 03/14/17, the resident said she did not have any leg braces. At 5:08 p.m. on 03/14/17, the Certified Occupational Therapy Assistant (COTA), #166 and the Director of Rehabilitation, Physical Therapist (PT) #162 were interviewed and asked if the resident needed to have hand splints or leg braces. PT #162 provided documentation the resident had been seen by therapy and hand splints were ordered in (MONTH) of (YEAR). She knew nothing about the leg braces. PT #166 was asked if the resident had contractures of her hands. She stated she would look at her tomorrow and would let me know. At 8:15 a.m. on 03/15/17, NA #27 said the resident was wearing both hand splints this morning when she arrived. She assisted the resident with getting up and getting dressed and she removed the hand splints. She described the splints as being the palm protectors on the resident's night stand. At 8:58 a.m. on 03/16/17, Occupational Therapist (OT) #169 said she had looked at the resident and did not feel she had a contracture. She said the resident opened her right hand and opened the left hand about half way She said the resident has [MEDICAL CONDITION] arthritis. She said, It looks like a contracture but she can open it halfway on the left side. At 10:00 p.m. on 03/16/17, the Director of Nursing (DON) said she found the physician's orders [REDACTED]. On 10/09/15, the order was discontinued and a new order written for a right resting hand splint to be worn from 6:00 p.m. - 8:00 p.m. with range of motion prior to application. The order for the left palm protector to be worn from 6:00 p.m. to morning, remained as written on 08/31/15. The DON said she never found any orders to discontinue the resting hand splint or the palm protector. The DON was advised the staff showed this surveyor two palm protectors being applied to both hands when the resident goes to bed and removed when she gets up in the morning. The DON said she would have therapy evaluate the resident again. At 3:20 p.m. on 3/16/17, the OT #169 said she evaluated the resident and she needs the hand splints. At 2:17 p.m. on 03/16/17, the Clinical Reimbursement Coordinator was interviewed regarding the care plan. The resident had no leg braces and is wearing hand splints without an order. The care plan says the resident has contractures, the MDS says she does not. He said he would look at the care plan and address the issues. No additional information was provided prior to exit.",2020-09-01
633,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,323,E,0,1,4QX611,"Based on observation and staff interview, the facility failed to ensure the soiled utility room on the second floor of the facility was locked. This was a random opportunity for discovery during the tour of the facility and had the potential to affect more than a limited number of residents. Facility census: 158. Findings include: a) Initial tour of the facility Observation of the soiled utility room, at 11:20 a.m. on 03/13/17, found the door not closed properly and unlocked. Inside the soiled utility room was a red, step on, garbage can containing biohazard materials. Housekeeping Aide #118 was asked to view the unlocked door as she was passing through the hallway. She immediately pulled the door closed and ensured the door was locked. This observation was discussed with the administrator and housekeeping supervisor on the morning of 03/17/17. No additional information was provided prior to exit.",2020-09-01
634,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,325,E,0,1,4QX611,"**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 three (3) of three (3) residents reviewed for the care area of nutrition received interventions to address their individual dietary needs. Resident #46 did not receive the therapeutic diet ordered by the physician, and did not receive the dietary interventions recommended by the registered dietician. Resident #166 did not receive pro-source (a non-carbohydrate liquid protein nutritional supplement) as directed by the physician. Resident #151 did not receive her diet as ordered for lactose intolerance. Resident identifiers: #46, #166 and #151. Facility census: 158. Findings include: a) Resident #46 The resident was reviewed for the care area of nutrition during Stage 2 of the Quality Indicator Survey (QIS) because the resident has a BMI (body mass index) of less than 22 and was not receiving nutritional supplements. The Resident's current BMI was 18.5. Review of the past three (3) nutritional assessment, completed by the Registered Dietician found the following assessment and documentation: 11/09/16 assessment: --Resident readmitted to facility last month, this is first available weight since readmission, hospital stay may be contributing to with loss noted below. Also noted recent ATB (antibiotic) orders and also oral candidias and ulcer in mouth noted, with meds (medications) per order: likely contributing to decreased intake. Meds include [MEDICATION NAME] may increase appetite, MVI (multivitamin) with minerals. Resident eats in second floor dining room. Likes hot tea with meals; also yogurt with meals. --Noted BMI was less than 19. --Intake is varying at this time, from 25-50% --Diet ordered was Regular/Liberalized diet House supplement BID x thirty days. 01/17/17, assessment: --The registered dietician noted the resident was to have a house supplement 2 times a day. --The intake observation was: -50% on average noted per available ADL (activities of daily living) entries. --The resident was noted to have a nutrition problem. --The interventions were: Regular/Liberalized diet House supplement BID in place. 02/15/17, assessment --Evaluated, continued with House Supplement two times a day. RD (registered dietician) review, weight up 4# this month, desirable. Meds include [MEDICATION NAME] (may increase appetite, MVI with minerals. Resident eats in second floor dining room. Likes hot tea with meals, other preferences noted per tray card. Large portions provided for additional calories. --Resident's intake was recorded as -50% on average intake noted per available ADL entries. Review of the current physician's orders [REDACTED]. There was a physician's orders [REDACTED]. Assigned Licensed Practical Nurse (LPN) #8 was asked if the resident received a supplement at 4:39 p.m. on 03/14/17. After review of the resident's MAR and TAR with this nurse she said, No, she doesn't get anything. Assigned Nurse Aide (NA) #9 said she thinks maybe the resident gets a supplement, once a day. She said she knows the resident likes vanilla shakes. She said she does not record the percentage of the supplement consumed. At 4:44 p.m. on 03/14/17, Cook #97 was interviewed regarding the resident's diet. She said the resident gets large portions of protein, like that would be a piece and 1/2 of meat. When asked about supplements, Cook #97 said the resident does not get a supplement. Observation of breakfast, on 03/15/17 at approximately 8:35 a.m., found the resident did not have extra portions. She had eggs, toast, and 2 pieces of bacon. NA # 44 verified the resident did not have extra portions on her breakfast tray. The Dietary Manager (DM) was interviewed at 4:40 p.m. on 03/15/17. The DM said the resident gets a house supplement two times a day. The DM was asked how he monitors if the resident is consuming the house supplement. He replied, he doesn't do any monitoring, that's the nurse's job. He said, It's nursing responsible to relay the message to me. When asked about the care plan, he replied, That is for the nursing staff, I don't look at that either. At 4:56 p.m. on 03/15/17, the Director of Nursing (DON) confirmed the percentages of supplement consumed by resident's are to be on the medication administration record. She confirmed Resident #46's percentages had not been recorded because the Resident did not have an order for [REDACTED]. Observation of the evening meal, at 5:30 p.m. on 3/15/17, found the resident received one (1) piece of fish, green beans, potatoes, a roll and dessert. Nurse Aides #62 and #9 verified the resident did not have large portions of food. Her food was the same size as the other resident's eating in the second floor dining room. The Speech Therapist #171 was also in the dining room feeding another resident. She did not believe the resident received extra portions on her tray. The resident did not receive yogurt with her meal as suggested in the 11/09/16 dietary assessment. An interview with Resident #46, at 5:30 p.m. on 03/15/17, found she said she didn't always like the food served. She was aware she could have a substitute but she probably wouldn't eat that either. She said, I just don't have an appetite, I wouldn't eat anything anyway. She said sometimes she get a shake that comes in a carton, like milk. She said she likes those and will drink them when she gets one. At 8:50 a.m. on 08/16/17, the Registered Dietician (RD) was interviewed. She says she monitors the effectiveness of her interventions by, I just ask the staff. This surveyor explained the staff appear confused as to if the resident even receives a house supplement, and there is no recording of the percentages of the house supplement the resident consumed. This surveyor asked the RD how a large portion of food would be effective when the resident was only eating less than 50% of her meals. She had no immediate answer for this question. b) Resident #166 Medical record review for Resident #166, on 03/16/17 at 10:15 a.m., found this resident receives [MEDICAL TREATMENT] due to end stage [MEDICAL CONDITIONS]. Laboratory result from the [MEDICAL TREATMENT] center dated 10/17/16 showed a 2.4 phosphorus level (normal level 3.0- 3.5). This lab results instructed the resident to consume 100 grams of protein each day and to take protein supplements three (3) times a day. Further review found an order dated 10/18/16 for: Prosource one scoop three (3) times daily and mix with 100 milliliters (ML) of food/fluid of choice as directed by dietician. Medication Administration Record (MAR) for Resident #166 reviewed found no documentation this supplement was given. In an interview, on 03/16/17 at 12:00 p.m., with the Director of Nursing (DON), revealed Resident #166 did not receive the Prosource as recommended and approved by the physician. No further information provided. Hoover, Regina, c) Resident #151 During interview with the resident on 03/14/17 at breakfast, she indicated she was unable to drink milk when the surveyor noted her milk had been opened. She said she was lactose intolerant and could not drink milk. A review of the tray card did say [MEDICATION NAME] under beverages but she had regular milk. Interview with the Registered Dietitian (RD), on 03/16/17 at 9:15 a.m., revealed the resident did not have an actual [DIAGNOSES REDACTED]. She said she would check to see why the resident did not receive [MEDICATION NAME]. The Director of Nursing, at 2:20 p.m. on 03/16/17, confirmed there was no actual [DIAGNOSES REDACTED]. Later the RD returned on 03/15/17and stated the Dietary Manager told her they were out of the [MEDICATION NAME] and would need to send someone to the store to get some until the milk order comes in later in the week. There was currently no [MEDICATION NAME] available to serve the resident. Review of current physician orders [REDACTED]. Additionally a RD assessment of 11/04/16 stated the resident does receive [MEDICATION NAME]. No additional information was provided prior to exit.",2020-09-01
635,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,329,E,0,1,4QX611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure each resident's drug regimen was free from unnecessary medications. The facility administered anti-anxiety and/or anti-psychotic medications to residents without documented target behaviors to warrant use. Furthermore, the facility failed to attempt non-pharmacological interventions prior to administering the anti-anxiety and/or anti-psychotic medications. This was true for three (3) of five (5) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #78, #145 and #114. Facility census: 158. Findings include: a) Resident #78 Review of Resident #78's medical record, on 03/16/17 at 11:00 a.m., revealed a physician's orders [REDACTED]. The order was written on 01/19/17. Further review of Resident #78's Medication Administration Record [REDACTED]. Additionally, there was no monitoring of side effects as well as no documentation of the targeted behaviors which warranted the use of the medication: --01/20/17 at 6:00 p.m. --01/21/17 at (time illegible) --01/22/17 at 10:30 a.m. and 9:00 p.m. --01/25/17 at 9:00 a.m. and 9:00 p.m. --01/26/17 at 9:00 a.m. and 9:00 p.m. --01/27/17 at 9:00 p.m. --01/28/17 at 10:30 p.m. --01/29/17 at 10:30 p.m. --01/30/17 at 9:00 a.m. and 9:00 p.m. --02/11/17 at 9:00 p.m. --02/19/17 at 9:00 p.m. --02/20/17 at 2:00 p.m. Nursing notes from 01/19/17 to 02/22/17 were reviewed. There was no documentation the resident was agitated and/or anxious at any time the [MEDICATION NAME] was administered, no documentation of attempts at nonpharmacological interventions before the administration of the [MEDICATION NAME], and no evidence the side effects were monitored during this time. The DON was interviewed, at 12:15 p.m. on 03/16/17, and she was unable to find documentation the resident exhibited any behaviors to warrant the use of [MEDICATION NAME]. The DON was also unable to provide evidence of attempts at nonpharmacological interventions prior to the administration of [MEDICATION NAME]. The behavior sheets were blank for side effect documentation. b) Resident #145 Review of the Medication Administration Record [REDACTED]. Review of the MAR for (MONTH) (YEAR) found the resident received the medication on the following dates: --03/01/17 at 9:00 p.m. --03/02/17 at 9:00 p.m. --03/04/17 at 9:00 p.m. --03/06/17 at 10:00 a.m. and 10:00 p.m. --03/07/17 at 10:00 p.m. --03/08/17 at 9:00 p.m. --03/10/17 at 10:00 p.m. --03/11/17 at 10:00 p.m. --03/12/17 at 10:00 p.m. --03/14/17 at 10:00 p.m. --03/15/17 at 10:00 p.m. The behavior for which the [MEDICATION NAME] was administered was listed as anxiety. Anxiety is a [DIAGNOSES REDACTED]. On 03/04/17, 03/08/17, and 03/14/17, there were no non-pharmacological interventions listed before administering the medication. The DON was interviewed at 11:18 a.m. on 03/16/17. She was unable to provide documentation of non-pharmacological interventions tried before administering the medication, [MEDICATION NAME] on 03/04/17, 03/08/17 and 03/14/17. In addition, the DON was unable to provide documentation of specific behaviors for which the medication was administered on any of the eight occasions in (MONTH) (YEAR). c) Resident #114 Record review found the resident was admitted to the facility on [DATE]. admitting [DIAGNOSES REDACTED]. The resident was prescribed [MEDICATION NAME] 0.5 milligrams, 1/2 tablet (0.25 milligrams) twice a day, as needed for a [DIAGNOSES REDACTED]. The medication, [MEDICATION NAME] was administered on 02/20/17, 02/24/17 and 02/27/17 according to the Resident's MAR. The unit charge Registered Nurse (RN) #52 verified, on 03/15/17 at 10:54 a.m., she was unable to find documentation of the behaviors the resident exhibited to warrant the use of [MEDICATION NAME] and was unable to find documentation of any non-pharmacological interventions implemented before given the medication. The resident's record contained no behavior monitoring sheets. At 10:54 a.m. on 03/15/17, the DON was unable to provide any further documentation of the behaviors exhibited to warrant the use of [MEDICATION NAME] and unable to provide documentation of the non-pharmacological interventions implemented before giving the medication. No additional information was provided prior to exit.",2020-09-01
636,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,364,E,0,1,4QX611,"Based on observation, temperature evaluation of foods, resident interview and staff interview, the facility failed to maintain food temperatures at acceptable ranges to keep food palatable and appetizing. This practice has the potential to affect more than a limited number of residents who receive food from this central location. Census: 158 Findings include: a) During an interview, on 03/14/17 at breakfast, the resident expressed concern with the temperature of her breakfast food items. At lunch on 03/15/17, the resident was observed to receive a mushroom burger and tator tots. She felt of these food items and said they were not warm. The surveyor requested a new tray for the resident and took temperatures of the food on the first tray. Temperatures were found to be 89 Fahrenheit (F) for the mushroom burger and 83 F the tator tots. Further review revealed the pellet warmer in the kitchen which is used to help keep plates warm was broken. Discussion with the Administrator, on 03/17/17 in the morning, indicated the unit had been broken and steps were being taken to obtain a different one. Additionally, steam table units used on each floor to serve food straight from a heated unit were no longer being used. This was due to a staffing issue in dietary not having enough trained staff to use this system. There were now enough staff and the facility hopes to restart this procedure soon. No additional information was provided prior to exit.",2020-09-01
637,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,371,E,0,1,4QX611,"Based on observations and staff interview, the facility failed to ensure stored and prepare food in in a safe manner. Outdated and/or unlabeled foods were found in the 1st floor cafe nourishment kitchen area and in the walk in refrigerator, the refrigerator unit for milk did not have a thermometer, equipment was found to be in need of cleaning, and staff was handling food in an unsanitary manner. This has the potential to affect more than a limited number of residents who are served from this central location. Census: 158 Finding include: a) A kitchen tour was conducted, on 03/13/17 beginning at 11:30 a.m., with corporate staff and the executive chef. The following issues were observed: 1. The chest type milk cooler did not have an internal thermometer to ensure the milk was being kept at a safe temperature. It was also noted to be in need of cleaning. There were many food crumbs, cereal and a kitchen knife in the bottom of the unit. 2. The walk in refrigerator was found to have a plastic container of sour cream which did not have a date of when it was opened. 3. Drip pans located under the range top were found to have foil which had a heavy accumulation of food debris and was in need of cleaning. Also a grease trap pan located near the stove top was noted to have lots of grease and food particles and in need of cleaning/changing. 4. Dietary staff were noted to have on gloves to serve foods. The same gloves were used to open loaves of bread, touching the outside wrapper of the bread and then touching the actual bread inside with the contaminated gloves. Additionally, the scoop used to dip the chicken salad on the bread was noted to have the handle placed directly in contact with the food product. 5. Observations in the 1st floor cafe revealed the corporate staff entered the cafe at 12:02 p.m. on 03/13/17. She proceeded to dispose of cartons of milk and shakes stored in the nourishment refrigerator which were dated expired as of 03/08/17 and 03/12/17. At least two (2) of each were noted. b) Observation of the second floor lunch service on 03/16/17 beginning at 12:28 p.m., found Nurse Aide (NA) #18, NA #29, NA #101, NA #27, and NA #49 serving sixteen (16) residents lunch. NA #18, #29, #101, #27 and #49 did not wash or sanitize their hands during the entire meal service. Also during this same meal the consistent practice of all the NA's was to pick small bowls and glasses up with their fingers touching the rim at the time of service and placing their thumbs inside the rims of resident's plates. During this time NA #49 carried a wrapped sandwich, a box of milk and a glass to a residents table. NA #49's forefinger was inserted inside the glass. On 03/17/17 at 10:45 a.m., this practice was described to the director of nursing who agreed the practice is not appropriate. No additional information was provided prior to exit.",2020-09-01
638,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,412,D,0,1,4QX611,"Based on record review and staff interview, the facility failed to obtain a dental assessment for one resident with a physician's order. This is true for one (1) of four (4) residents reviewed for dental care. Resident identifier: #59. Facility census: 158. Findings include: a) Resident #59 Review of records for Resident #59 revealed a physician order dated 01/04/17 to schedule the resident an appointment with dentist due to an oval growth on the right upper gum. Continued review of the records found no evidence Resident #59 was evaluated by a dentist. On 03/16/17 at 1:00 p.m., Registered Nurse #52 stated the appointment did not occur. She also stated Resident #59 has an appointment for a dental assessment on this same day 03/17/17 at 2:30 p.m. No additional information was provided prior to exit.",2020-09-01
639,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,428,E,0,1,4QX611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed ensure to protect two (2) of five (5) residents reviewed for care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). The facility failed to ensure the gradual dose reduction for Resident #78, was administered as ordered by the physician. Additionally, the consultant pharmacist failed to identify the use of as needed anti-anxiety medication for Resident #114, was administered without targeted behaviors, non-pharmacological interventions and side effects being monitored. Resident identifiers: #78 and #114. Facility census: 158. Findings include: a) Resident # 78 Review of records, on 03/15/17 at 3:26 p.m., revealed a Pharmacy Consultation Report for (MONTH) (YEAR), issued on 02/01/17. This Pharmacy Consultation Report contained the recommendation to consider decreasing Citalopram (Celexa) to 20 milligrams (mg) daily. On 02/16/17, the recommendation was signed and approved by the facility's nurse practitioner (NP). Additionally, on 02/16/17, a handwritten order by the NP was found in the physician orders [REDACTED]. On 03/16/17 at 10:27 a.m., review of (MONTH) (YEAR) Medication Administration Record [REDACTED]. Interview with Director of Nursing (DON), on 03/16/17 at 10:42 a.m., revealed the licensed nurses continued to give 40 mg of Citalopram even after the NP had written an order to decrease the Citalopram to 20 mg on 02/16/17. No further information provided. b) Resident #114 Record review found the resident was admitted to the facility on [DATE]. admitting [DIAGNOSES REDACTED]. The resident was prescribed Xanax 0.5 milligrams (1/2 tablet = 0.25 milligrams) twice a day, as needed for a [DIAGNOSES REDACTED]. The medication, Xanax was administered on 02/20/17, 02/24/17 and 02/27/17 according to the Resident's MAR. The unit charge Registered Nurse (RN) #52 verified, on 03/15/17 at 10:54 a.m., she was unable to find documentation of the behaviors the resident exhibited to warrant the use of Xanax and was unable to find documentation of any non-pharmacological interventions implemented before given the medication. The resident's record contained no behavior monitoring sheets. The pharmacist completed a review of the resident's medications on 03/02/17. The pharmacist noted an issue with the resident's potassium chloride but did not identify the resident had received the as needed medication Xanax with evidence of behaviors to warrant its use and without evidence non-pharmacological interventions were tried before giving the medication. At 10:54 a.m. on 03/15/17, the DON was made aware of the above information. She was unable to provide any further documentation of the behaviors exhibited to warrant the use of Xanax and unable to provide documentation of the non-pharmacological interventions implemented before giving the medication. She reviewed the consultant pharmacist report, dated 03/02/17. She confirmed the use of Xanax was not identified by the pharmacist. No additional information was provided prior to exit.",2020-09-01
640,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,431,D,0,1,4QX611,"Based on observation, review of the guidelines in Appendix PP of the State Operations Manual, and staff interview, the facility failed to ensure the consultant pharmacist maintained a formal system for safe and secure use and storage of medications. There was no permanently affixed storage container in the refrigerator for the secure storage of controlled medications. This practice had the potential to affect no more than an isolated number of residents. Facility census: 158. Findings include: a) Observation of the 3rd floor medication room, on 03/16/17 at 9:55 a.m., revealed the medication refrigerator contained two (2) boxes with thirty (30) milliliter vials of Lorazepam lying on the top shelf of the refrigerator. b) Licensed Practical Nurse (LPN) #26 was present at the time of the observation of the medication refrigerator. She verified the two (2) boxes in the medication refrigerator containing narcotic (Lorazepam) was not in a permanently affixed container in the refrigerator. c) The State Operations Manual (SOM), Appendix PP includes The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. d) In an interview, with the Unit Manager (UM) #11, on 03/16/17 at 10:05 a.m., she agreed the medication refrigerator had no permanently affixed container for the storage of Ativan in the refrigerator. e) The Director of Nursing (DON) was informed, on 03/16/17 at 11:32 a.m., the medication refrigerator on 3rd floor had no permanently affixed container in which to store the Ativan. No additional information was provided prior to exit.",2020-09-01
641,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,441,D,0,1,4QX611,"Based on medical record review and staff interview, the facility failed to maintain an effective infection control program to prevent, to the extent possible, the onset and spread of infection. During Stage 1 of the Quality Indicator Survey, random opportunities found two (2) residents to have oxygen equipment which was soiled or stored in a manner for potential contamination. Resident identifiers: #138 and #30. Facility census: 158. Findings include: a) Resident #138 On 03/13/17 at 1:33 p.m., Resident #138's oxygen tubing was lying directly on the floor without a barrier and the oxygen concentrator was found to without an air filter. At 8:45 a.m. on 03/17/17, the oxygen concentrator was again observed with no air filter. b) Resident #30 On 03/13/17 at 1:58 p.m., Resident #30's oxygen concentrator was observed to have a heavy layer of visible dust on the air filter. Registered nurse #52 was informed of the oxygen tubing being on the floor and the problems with the oxygen concentrators, on 03/17/17 at 9:09 a.m., and she stated she would have the concentrators checked. No additional information was provided prior to exit.",2020-09-01
642,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,502,D,0,1,4QX611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to promptly obtain all physician ordered laboratory (lab) services to meet the needs of residents. Resident #166 had orders for a Basic Metabolic Panel (BMP), [MEDICATION NAME]/International Ratio (PT/INR) and ammonia level to be obtained on 10/21/16 which was not obtained by the facility. Resident #78 has an order for [REDACTED]. Resident identifiers: #166 and #78. Facility census: 158. Findings include: a) Resident #166 A review of Resident #166's medical record, on 03/15/17 at 11:34 a.m., found a physician's orders [REDACTED]. The results of these labs could not be found in the resident's medical record. On 03/16/17 at 11:08 a.m., the Director of Nursing (DON) indicated the BMP, PT/INR and the ammonia level which was ordered for 10/21/16 were not obtained therefore no lab results could be provided. b) Resident #78 A review of Resident #78's medical record, on 03/16/17 at 10:34 a.m., found a physician's orders [REDACTED]. The results of these labs could not be found in the resident's medical record. On 03/16/17 at 11:08 a.m., the Director of Nursing (DON) indicated the BMP ordered for 01/21/17 was not obtained therefore no lab results could be provided. No additional information was provided prior to exit.",2020-09-01
643,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,550,E,0,1,FJW311,"Based on observations and staff interview, the facility failed to ensure residents in the main dining room on first floor had a dignified dining experience. After the meal service began, service was stopped because pureed food was not available for over twenty-five (25) minutes. This had the potential to affect all residents receiving meals in the first floor dining room. Facility census: 156. Findings include: a) Observation of the first-floor dining room Observation of the first-floor dining room at 11:45 a.m. on 04/23/18, found residents seated at approximately six (6) different tables in the dining room. Employee #76, the director of guest services, served the buffet style meal from an enclosed steam table centered in the dining room. Three (3) residents, #69, #34, and #10, who had already been served plates of food, sat at a table together. Resident #52, seated at the same table, had only a bowl of vegetable soup. At 12:06 p.m. on 04/23/18, when asked why residents were not receiving their food, Employee #76 said she did not have any pureed foods on the steam table and was waiting for the kitchen to bring some pureed foods. She said she started serving food to the residents at the first table and realized Resident #52 needed pureed meat for his sandwich so she had to stop service. She said she had offered some of the other residents a bowl of soup, if their diet allowed, so they would at least have something to eat while waiting for the kitchen to send pureed food. Employee #76 said she started serving the residents in the dining room around 11:30 a.m. At 12:10 p.m. on 04/25/18, the dietary manger arrived with the pureed food items and the tray line resumed. The dietary manager said the facility had plenty of food, but someone had not pureed enough food.",2020-09-01
644,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,553,D,0,1,FJW311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Base on record review, resident interview, and staff interview, the facility failed to ensure a resident's right to participate in the development of her person-centered plan of care. This was a random opportunity for discovery for one (1) of thirty-one (31) residents during the initial screening process. This practice had the potential to affect more than a limited number of residents. Resident Identifier: #150. Facility census: 156. Findings include: a) Resident #150 The initial interview with Resident #150, on 04/23/18 at 11:12 AM, revealed the resident did not receive a summary of her initial care plan when admitted , or for any care plan since her admission to the facility on [DATE]. The resident was unaware of what care areas, goals, or interventions were in her care plan. The resident denied ever seeing a care plan or signing one. On 04/25/18 at 11:33 AM, a review of the resident's last quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 03/14/18 found the resident assessed as having clear speech, as able to be understood, and able to understand others. Resident #150's Brief Interview for Mental Status (BIMS) score of fifteen (15) identified the resident was cognitively intact. On 04/25/18 at 04:15 PM, a review of records with the Director of Nursing (DON), revealed a summary of care conference form with no signature in the designated section to indicated the resident attended the meeting. The DON agreed there was no signature, and without the signature, the DON could not know if the resident attended. The facility did not provide any evidence the resident was included in the development of her care plan by the conclusion of the survey.",2020-09-01
645,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,558,D,0,1,FJW311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility failed to accommodate the needs of one (1) randomly observed resident. Observations found a resident with her feet hitting against the footboard of the bed without anything for comfort to reduce pressure when the head of her bed was elevated. This was evident for one (1) randomly observed resident. Resident identifier: #20. Facility census: 156. Findings included: a) Resident #20 Observations of the resident noted: - On 04/23/18 at 5:24 p.m. her feet touched the footboard, even though staff had pulled her up in the bed not long ago. She was confused and disoriented, and not able to interview regarding her comfort level - On 04/25/18 at 9:15 a.m. the head of her bed was elevated, and her toes were against the footboard of the bed. - On 04/25/18 at 4:00 p.m. head of her bed was slightly elevated. Her toes touched the footboard. - On 04/25/18 at 5:37 p.m. the head of her bed was elevated, and her feet touched the footboard of the bed. None of the observations found application of any interventions to lessen the pressure on her feet and toes from the footboard. Medical record review on 04/25/18 found this resident's most recent quarterly minimum data set (MDS) with an assessment reference date of 01/16/18 assessed her as needing the extensive of assistance of two (2) or more persons for bed mobility. The assessment also identified her as short of breath when lying flat, when sitting at rest, and on exertion. According the assessment, the resident was 66 inches tall and weighed 266 pounds, and was assessed as being at risk for pressure ulcer development. She also had a [DIAGNOSES REDACTED]. During an interview on 04/25/18 at 6:00 p.m., the director of nursing (DON) said they did not approve of residents' feet hitting the footboards of their beds. She said there were other things they could use to prevent this from occurring, such as pillows or wedges. On 04/26/18 at approximately 9:30 a.m., these findings were discussed the administrator. The facility provided no further information prior to the survey exit conference.",2020-09-01
646,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,561,D,0,1,FJW311,"Based on resident interview, staff interview, and record review, the facility failed to accommodate a resident's choice of when he could shower. This was a random opportunity for discovery during the initial screening process of the annual survey. Resident identifier: #119. Facility census: 156. Findings included: a) Resident #119 During an interview on 04/23/18 at 10:54 AM, Resident #119 said Unit Manager (UM) #13 told him he could only have two (2) showers a week. He reported that two (2) weeks ago he only got one (1) shower because the shower room was closed. He said if could have more showers his skin would heal. On 04/23/18 at 1:00 PM, the resident's concern was discussed with the Director of Nursing (DoN). When told Resident #119 wanted more than two (2) showers a week, she agreed he should have more showers if he wanted them more often. She said that she would talk to the floor manager (UM #13) about his showers. During an interview on 04/24/18 at 2:46 PM, Resident #119 said the Unit manager told him she would have to look at the shower schedule before she could give him more showers a week and that no showers were given on Sundays. He said he was hoping to get a shower on Sundays for when he had visitors. He said currently he could only have a shower on Tuesday and Thursday so by Sunday he said he was pretty ripe. During an interview on 04/24/18 at 2:54 PM, Unit Manager #13 said she did not recall this resident asking for more showers and she would look into finding him another shower day, but they did not give showers on Sundays because it was closed. According to the UM, the cleaning crew did a heavy cleaning on the shower tiles on Sundays. When asked if it took all day to clean the shower, and if not could he get a shower before or after the cleaning, she stated she would have to check with housekeeping first. She further stated that it would not happen right away because she would have to redo the shower schedule and added there was not enough staff for him to have more showers. On 04/24/18 at 3:36 PM, when informed of what UM #13 had said, the DoN said, I can't believe that she would say that! I just did an education sheet with her yesterday about allowing him to have more showers when he wants and she agreed to accommodate his needs. She claimed he would receive a shower whenever he wanted. A review of Resident #119's care plan dated 03/25/17, found it identified the resident's preference was to shower three (3) days a week.",2020-09-01
647,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,600,J,0,1,FJW311,"**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 each resident was free from verbal abuse and neglect. The facility failed to provide timely incontinence care to Resident #119. The resident also tearfully reported being verbally abused by a nurse aide because he had called the nurses' station for help after no one responded to his call bell for thirty (30) minutes. The lack of incontinence care and the verbal abuse caused the resident to experience pain, skin breakdown, and psychological harm. Until the surveyor identified the resident's problems and intervened, staff were not aware of the seriousness of his condition. These findings were determined to constitute immediate jeopardy to Resident #119. After consultation with the Office of Health Facility Licensure and Certification (OHFLAC) at 1:25 PM on 04/25/18, and preparation of a written statement, the Administrator and Director of Nursing were notified of the Immediate Jeopardy. The facility provided an acceptable at 4:17 PM on 04/25/18. After verifying implementation of the plan of correction, the immediate jeopardy was abated at 5:26 PM on 04/25/18. No deficient practice remained for this requirement after removal of the immediate jeopardy. This affected one (1) of seven (7) residents reviewed for activities of daily living. Resident identifier: #119. Facility census: 156. Findings included: a) Resident #119 During the initial screening for the Long Term Care Survey Process, an interview on 04/23/18 at 11:37 AM, Resident #119 stated he had a pressure ulcer on his buttock from sitting in urine for 30 minutes or longer. He went on to explain he could not walk, that he tried to use a urinal, but sometimes did not get all of the urine in the urinal. Medical record review found his [DIAGNOSES REDACTED].>- muscle weakness - heart failure - Retention of urine - Type 2 Diabetes underlying condition with hyperosmolarity - Chronic [MEDICAL CONDITIONS] - Obesity - History of pressure ulcers on the right heel and penis According to his minimum data set assessment (MDS) with an assessment reference date (ARD) of ____, his Brief Interview for Mental Status Score (BIMS) was 15, indicating he was cognitively intact. Review of his medical records found no mention of current pressure ulcers. Skin Check Performed Sheets dated from 01/27/18 to 04/23/18 documented the following: - 01/27/18- No Skin Injury/Wounds by Licensed Practical Nurse (LPN) #172 - 02/04/18 -No Skin Injury/Wounds by LPN #92 - 02/10/18- No Skin Injury/Wounds by LPN #172 - 02/17/18- No Skin Injury/Wounds by LPN #92 - 02/24/18- No Skin Injury/Wounds by LPN #172 - 03/03/18- No Skin Injury/Wounds by LPN #92 - 03/10/18- No Skin Injury/Wounds by LPN #172 - 03/17/18 -Yes Skin Injury/Wounds identified No New Skin Injury/Wounds Type of Skin Injury/Wounds Moisture Associated Skin Damage by Registered Nurse (RN) #4 - 03/24/18- No Skin Injury/Wounds by LPN #172 - 04/02/18- No Skin Injury/Wounds by RN #4 - 04/07/18- No Skin Injury/Wounds by LPN #33 - 04/23/18 -No Skin Injury/Wounds by LPN #92 On 04/25/18 at 9:15 AM, Wound Care Nurse #120 agreed to do a complete skin assessment with the surveyor present. On entering the room, Resident #119 was emotional and tearful saying that he was, chewed out, by Nurse Aide #96 for calling the nurses' station with his cell phone. He stated that she told him to only use his call light that was what it was for and not to call the nurses' station again. He said NA #96 told him that he was not the only one on this floor and he just needed to wait his turn. He said he responded by telling her he used the call light and had been waiting for more than 30 minutes before he called the nurses' station with his cell phone because his skin was on fire from sitting in urine. Resident #119 told this to the surveyor, Wound Care Nurse #120, and Nurse Aide #84. With the resident's permission, Wound Care Nurse #120 pulled the sheets back revealing a very large red excoriation on his upper outer thighs. Further investigation found areas of broken skin under his scrotum and coccyx. The resident's tee shirt was saturated with urine up his back and had small amount of stool on the bottom. The resident said NA #96 had changed him, therefore the nurse aide left him with a soiled shirt. Wound Care Nurse #120 removed the resident's tee shirt. When the nurse asked how long his skin had been in this condition, the resident replied it had been a year - that it started after being on this floor for a week. The complete skin audit by Wound Care Nurse #120 found: - 1. Pressure Ulcer Stage II on Coccyx - 2. Pressure Ulcer Stage II on right ear - 3. Excoriated areas bilateral groin, under both breast, bilateral abdominal folds, bilateral upper outer thighs and bilateral calf's. - 4. Reddened area to the right great toe, second and third toes, right heel. During an interview on 04/25/18 at 9:35 AM, Wound Care Nurse #120 stated that he was, Just mortified by what was just discovered, referring to the condition of Resident #119's skin. He went on to say he had no excuse and they had failed this resident. On 04/25/18 at 9:45 AM, the DoN was informed of the findings for Resident #119. She said she was already aware and was working on a plan of correction. On 04/25/18 at 1:10 PM, Resident #119 said that he was still upset over the NA #96 fussing at him that morning and it was not the first time he had had to wait for over 30 minutes for assistance. He went on to say he had called his wife many times to have her call the facility to ask them to help him. The resident's care plan, dated 04/03/17 included a plan for impaired skin integrity due to his psoriasis, Moisture Associated Skin Damage (MASD), and history of pressure ulcers. The interventions were: - Monitor skin for signs/symptoms of skin breakdown i.e. - Observe skin condition with ADL care daily and report abnormalities - Skin check per policy - Weekly skin assessment by license nurse - Weekly wound assessment The facility's policy, NSG236 Skin Integrity Management Effective date 07/01/01, Revision date 11/28/16, directed the staff to continually observe and monitor for skin changes and implement revisions to the plan of care. The purpose, to provide safe and effective care to prevent the occurrence of pressure ulcers and promote healing of all wounds The facility's policy,OPS300 Abuse Prohibition, effective date 06/01/96 Revision date 04/07/17, stated all employees would be trained ongoing to prevent abuse. The facility reported the resident's allegations concerning NA #96 to the Nurse Aide Program at OHFLAC on 04/26/18. These findings were determined to constitute immediate jeopardy to Resident #119. After consultation with the Office of Health Facility Licensure and Certification (OHFLAC) at 1:25 PM on 04/25/18, and preparation of a written statement, the Administrator and Director of Nursing were notified of the Immediate Jeopardy. The facility provided an acceptable at 4:17 PM on 04/25/18. After verifying implementation of the plan of correction, the immediate jeopardy was abated at 5:26 PM on 04/25/18. No deficient practice remained for this requirement after removal of the immediate jeopardy. The Facility's Plan of Correction: On 04/25/18 The RN wound nurse evaluated Resident #119's skin at 3:50 PM, a pain assessment was conducted by RN wound nurse at 3:50 and a Social Worker (SW)/designee will interview the resident on 04/25/18 by 5 PM, to address alleged psychological harm with corrective action upon discovery. The physician was notified of changes at 3:50 PM, by RN wound nurse. On 04/25/18 the center SW reported the allegation of neglect to the appropriate state agencies at 10:44 AM. All residents of the facility have the potential to be affected. The DON/designees will begin to conduct observation of all residents' skin on 04/25/18 with corrective action upon discovery. SW/designees will begin to interview all interview able residents on 04/25/18 to ensure that incontinence care and pain are addressed timely and that residents have not experienced any psychologic harm as evidenced by lack of verbalized fear and be completed by 04/25/18 with corrective action upon discovery. The DON/designees will begin observations of non-interview able residents' skin sweeps on 04/04/25/18 and completed by 04/26/18, including completion of the non-interview able pain evaluation with corrective action upon discovery. The Nurse Practice Educator (NPE)/designee will re-educate all licensed staff on accurate completion and documentation of the weekly skin checks to monitor the patients and his/her wound's response to treatments and interventions beginning on 04/25/18 and all center staff will be re-educated to ensure all center residents are free from neglect, including pain and psychological harm, respond to residents in a timely manner with a post-test to validate understanding beginning 04/25/18. Staff not available during this timeframe will be provided re-education including post-test by the NPE/designee, upon return to work. New hires will be provided education and post-tests during orientation by the NPE/designee. The Unit Managers (UMS)/designee will conduct observation of weekly skin checks, timely response of continence care, pain monitor flow sheets daily for two weeks across all shifts including weekends, then three times a week for two weeks then randomly thereafter to ensure that weekly skin checks are accurate, incontinence care is provided in a timely manner to avoid skin breakdown, and residents pain is addressed based on daily MAR pain evaluation. The SW/designee will conduct sixteen (16) random interviews daily for two weeks across all shifts including weekends, then three times a week for two weeks then randomly thereafter to ensure that residents do not experience any neglect or psychological harm. Trends identified will be reported by the DON monthly to the Quality Improvement Committee (QIC) for any additional follow up and/or in-servicing until the issue is resolved and randomly thereafter as determined by the QIC.",2020-09-01
648,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,607,D,0,1,FJW312,"Based on abuse prohibition policy review, a review of grievances and staff interview the facility failed to ensure they implemented their abuse prohibition policy for identifying allegations of neglect, reporting allegations of neglect and identifying whether a resident's missing money involved misappropriation of property. They failed to identify and report an allegation of neglect for one of four (4) grievances reviewed. The facility also failed to identify whether a resident's missing money constituted misappropriation of property for one (1) of four (4) grievances reviewed. A grievance for Resident #154 stated the resident's catheter bag was not checked, for a long period of time and was leaking. Resident #110's grievance reflected that he had six (6) one (1) dollar bills missing. Resident identifiers: #110, #154. Facility census: 155. Findings included: a) Resident #154 A review of the facility's grievance/concerns for the month of (MONTH) (YEAR) found the facility had received a grievance/concern from Resident #154 on 07/10/18. The documentation on the grievance/concern stated, Resident states no one checked her cath (catheter) bag from 4 pm Friday to 1 pm Saturday. When it was checked it was found to be leaking. The resolution of the grievance/concern stated, Staff re-educated on Policy/Procedure of catheter observation and emptying of bedside drain. During an interview with Social Worker (SW) #1, on 07/24/18 at 11:45 AM, the SW said the facility had investigated this issue and found that the resident's catheter bag had been checked and the resident was not upset. She said the resident had no mental anguish and that was why they did not consider the issue as an allegation of neglect. A review of the facility's abuse prohibition policy, revision date 07/01/18, revealed neglect was defined as, The failure of the Center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy also stated the facility would identify incidents or allegations which needed investigated. b) Resident #110 A review of the facility's grievance/concern forms from the month of (MONTH) (YEAR) revealed a grievance/concern for Resident #110 dated 07/05/18. The form stated, Resident states he is missing 6 one dollar bills. On 07/24/18 at 1:47 PM Registered Nurse (RN) #1 said she was the staff member to whom this concern was reported. She said she remembered Resident #154 talking to her about the missing money and telling her he thought he left it in his drawer. RN #1 said she also knew the resident was sick during the time the money was reported missing. The money was later found in the laundry. During an interview with Clinical Quality Specialist (CQS) #152 and RN #1 on 07/24/18 at 1:47 PM, both were asked how the facility determined if they were dealing with a situation of misappropriation of property. CQS #152 said she realized the facility should have documented more of the details surrounding the resident's statement when the money was reported missing on 07/05/18. She agreed that the details on the grievance/concern form did not give enough information to show whether the facility had a situation involving misappropriation of property. A review of the facility's abuse prohibition policy, revision date 07/01/18, revealed the policy defined misappropriation of property as, The deliberate misplacement, exploitation, or wrongful temporary or permanent use of patient's belongings or money without the patient's consent. The policy also stated the facility would identify possible incidents or allegations which need investigation.",2020-09-01
649,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,609,D,0,1,FJW312,"Based on policy review, staff interview, and a review of grievances/concerns for the month of (MONTH) (YEAR), the facility failed to ensure an allegation of neglect was reported. Resident #154 had reported that her catheter bag had not been checked for a long period of time and was leaking. Resident identifier: 154. Facility census: 155. Findings included: a) Resident #154 A review of the facility's grievance/concerns for the month of (MONTH) found the facility had received a grievance/concern from Resident #154 on 07/10/18. The documentation on the grievance/concern stated, Resident states no one checked her cath (catheter) bag from 4 pm Friday to 1 pm Saturday. When it was checked, it was found to be leaking. The resolution of the grievance/concern stated, Staff re-educated on Policy/Procedure of catheter observation and emptying of bedside drain. During an interview with Social Worker (SW) #1, on 07/24/18 at 11:45 AM, the SW said the facility had investigated this issue and found that the resident's catheter bag had been checked and the resident was not upset. The grievance concern documentation showed where the facility had conducted an in-service training on 07/10/18 for Foley catheter care. SW #1 said the resident suffered no mental anguish from the situation and that was why they did not consider the issue to constitute an allegation of neglect. During the interview, on 07/24/18 at 11:45 AM, SW #1 confirmed this issue was not reported as an allegation of neglect. A review of the facility's abuse prohibition policy, revision date 07/01/18, revealed neglect was defined as, The failure of the Center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy also stated the facility would identify possible incidents or allegations which need investigation and report allegations involving neglect within 24 hours.",2020-09-01
650,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,641,E,0,1,FJW311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, facility failed to accurately complete the Minimum Data Set (MDS) assessments to reflect each resident's status. This was true for six (6) of thirty-one (31) sampled residents. The facility did not conduct interviews with Resident #202 that the resident could have completed. Resident #152 assessment did not accurately reflect the resident's prognosis. Resident #103 assessment was inaccurate regarding restraint usage. Resident #113's assessment did not identify the resident had experienced a fall with major injury. Resident #55's assessment did not identify the resident's weight loss and Resident #99's assessment did not identify contractures. Resident identifiers: #202, #152, #103, #113, #55, and #99. Facility Census: 156. Findings included: a) Resident #202 Beginning 04/24/18 at 10:00 a.m., record review found the resident, admitted on [DATE], had [DIAGNOSES REDACTED]. On 03/17/18, the resident experienced a stroke resulting in weakness of his right side, severe [MEDICAL CONDITION], and hypertension. The discharge summary noted the resident was alert to situation could answer by nodding his head, or by using pictures or writing. Observations on 04/23/18 found the resident outside smoking in the designated area. This observation noted no safety issues. Further review of records found on 04/05/18, the physician had declared the resident had capacity to make his own medical decisions. Review of Resident #202's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 04/10/18, found resident interviews were not completed for Sections C- Cognitive Patterns, D - Mood, and J Health Conditions which includes a pain interview, were not completed with Resident #202's participation due to his severe [MEDICAL CONDITION] (inability to communicate verbally). Although the resident could not respond to questions verbally, he was able to effectively communicate by shaking his head yes/no, by using pictures, and/or writing. During an interview on 04/24/18 at 2:15 p.m., the Director of Nursing (DON) confirmed the resident was alert and oriented, but unable to express his needs/requests verbally, but able to communicate through pictures/writing and nodding of his head. She asked social services to redo the resident's Brief Interview Status (BIMS) (indicates cognitive status) and nursing to re-evaluating his mood and pain levels using techniques in which the resident could participate. She confirmed the resident's admission MDS was inaccurate. b) Resident #152 Medical record review, beginning on 04/24/18 at 9:10 a.m., found the resident was admitted to the facility on [DATE]. Review of Resident #152's discharge records from the hospital found a consultation with an oncologist (cancer) physician dated 12/23/17. The Assessment and Plan included, . eighty-five year old female well known to me, because I have been following her for her metastatic [MEDICAL CONDITION] . Unfortunately, she does have an incurable disease, that is, treatment is mainly palliative in nature . Stage IV (4) [MEDICAL CONDITION] with multiple skeletal metastasis Review of the resident's admission MDS with an ARD of 01/02/18, found Section O identified the resident was receiving hospice care, but Section J did not indicate the resident had a prognosis of six (6) months or less. An interview with the DON on 04/24/18 at 3:30 p.m., confirmed the MDS with ARD of 01/02/18 was inaccurate. c) Resident #103 Observations, beginning on 04/23/18 at 10:00 a.m., found the resident sitting in a highbacked wheelchair with a foot cradle and a waist restraint. This observation noted the resident had uncoordinated hand, leg, and body movements and some shrill vocalizations were noted. Further record review found Resident #103 had a [DIAGNOSES REDACTED]. The record included documentation of multiple falls from the wheelchair prior to the use of the waist restraint due to the movement of the resident's arms, legs and trunk. A waist/trunk restraint was used when Resident #103 was up in a wheelchair to reduce falls with injuries. The resident's MDS with an ARD of 03/13/18 indicated the resident used a trunk restraint daily when in bed. During an interview on 04/25/18 at 3:30 p.m., the DON confirmed the MDS was inaccurate as the trunk restraint was only used when the resident was up in the wheelchair. . d) Resident #113 On 04/26/18 at 09:46 AM, review of records revealed a minimum data set (MDS), with an assessment reference date (ARD) 03/07/18, with a discrepancy for Item J1900 concerning falls with major injury. The instruction manual for completing MDS assessments defines major injury as bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma. The item was marked zero (0), indicating the resident did not have any major injuries. However, the resident's medical record identified the resident had a fall on 01/04/18 and was unconscious for one (1) to two (2) minutes. When interviewed on 04/26/18 at 12:33 PM, the DON concurred that a resident falling and hitting his/her head and losing consciousness would be classified as a major injury. After reviewing the resident's records, the DON agreed the MDS was inaccurately coded for falls with major injury. e) Resident #55 The resident's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 04/13/18, indicated No or unknown for the item regarding weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Review of the weights summary for Resident #55 revealed the resident weighed 136 pounds on 03/12/18. On 04/10/18, the resident weighed 109 pounds. This was a weight loss of 20% in one (1) month. During an interview on 04/26/18 at 11:36 AM, the Center Nurse Executive agreed the assessor should have answered, Yes, not on physician-prescribed weight loss regimen for the item Loss of 5% or more in the last month or loss of 10% or more in the last 6 months. f) Resident #99 Observation of this resident on 04/24/18 at 10:45 a.m. found her left hand with contractures at the wrist. Her fingers were bent down into her palm. She had no splint, palm guard, or rolled washcloth in use at the time of the observation. Registered Nurse, Employee #13 (E#13) tried to straighten the resident's bent fingers as much as possible without causing pain to allow the palm to be inspected. E#13 said they used to use a rolled washcloth in her hand, but thought that therapy only used a rolled washcloth during certain hours of the day now. Review of the significant change minimum data set (MDS) with an assessment reference date (ARD) 01/12/18, found the resident assessed as having no contractures of either hand. Review of the five (5) day MDS, with ARD 04/12/18, assessed her as having no contractures of either hand. On 04/25/18 at 6:00 p.m., during an interview with the director of nursing (DON), it was discussed that the 01/12/18 significant change MDS and the five (5) day MDS of 04/12/18 contained incorrect assessments of the resident's left hand contracture. The DON was aware of the resident's contracted left hand and agreed the assessments were incorrect in that area. These findings were discussed with the administrator on 04/26/18 at approximately 9:30 a.m. No further information was provided by the facility prior to exit",2020-09-01
651,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,656,E,0,1,FJW311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interview, the facility failed to ensure a person centered comprehensive care plan was developed/and or implemented for three (3) of thirty-one (31) residents reviewed. The facility failed to develop a resident centered care plan for Resident #109 who was a double [MEDICAL CONDITION]. Resident #26's care plan was not implemented regarding providing extensive assistance with personal hygiene. A care plan was not developed for Resident #128 to include care and treatment of [REDACTED].#109, #26, and #128. Facility census: 156. Findings included: a) Resident #109 Record review found the resident was admitted to the facility on [DATE]. The resident's care plan identified a problem of, Resident is at risk for compromised peripheral circulation [MEDICAL CONDITION]/PAD ([MEDICAL CONDITION]/peripheral artery disease) [MEDICAL CONDITION]. The goal associated with the problem was, The resident will experience maximum peripheral circulation with minimal complications through next review. Interventions included, Float heels as indicated. During an interview at 10:12 a.m. on 04/24/18, the Director of Nursing (DON) confirmed the resident was a double [MEDICAL CONDITION]. She said the resident had a right above the knee amputation and a left [MEDICAL CONDITION] around (MONTH) (YEAR). The DON said, I don't know why that would be on the care plan. b) Resident #26 Review of the resident's care plan found a focus/problem of, Resident requires assistance with ADL's (activities of daily living) due to limited mobility. The interventions for the problem included: - Monitor for decline in ADL function. - Refer to rehabilitation therapy if decline in ADL's in noted. - Provide resident extensive assist for bed mobility, dressing, eating, personal hygiene and grooming. Observation of the resident at 4:45 p.m. on 04/23/18, found both the resident's left and right hands appeared to be contracted. Observation of the resident at 1:44 p.m. on 04/25/18, with Occupational Therapist (OT) #171 revealed the OT could open the resident's right hand with without difficulty. When opened, a sour odor, coming from the resident's right hand was evident. OT #171 said, I have sinuses, and could not smell the odor. When OT #171 attempted to open the resident's left hand, a strong putrid, foul smelling, sour odor, emanated from resident's hand. OT #171 did acknowledge she could smell the odor coming from the left hand. OT #171 said she would get staff to clean the resident's hands. When OT #171, discarded her gloves in the trash can in the corner of the resident's room, the foul odor from the gloves could be smelled coming out of the trash can. At 2:15 p.m. on 04/25/18, Licensed Practical Nurse (LPN) #26 was observed cleaning the resident's hands and cutting the resident's fingernails. The LPN acknowledged both hands had a foul odor. At 8:10 a.m. on 04/26/18, observation of the resident with the DON found the resident still had a slight odor coming from the left hand. The DON said she was going to get an order for [REDACTED]. At 9:21 a.m. on 04/26/18, the DON confirmed the resident did not receive extensive assistance with personal hygiene as directed by the care plan. She confirmed staff were not providing care and cleaning to the resident's hands. c) Resident #128 Resident #128 received nutrition through a gastrostomy tube (G tube - a tube inserted through the abdomen into the stomach to deliver nutrition). Review of physician's orders [REDACTED]. The physician also ordered, Flush tube with 200 cc of H2O (water) q (every) 4hrs. On 04/24/18 at 10:46 AM, review of resident's care plan found it was not individualized to reflect care concerning his feeding tube. The care plan did not identify the caloric value of the enteral (tube) feeding or the mechanism of administration of the feeding. The care plan directed to flush the tube as ordered, but did not include how often and with how much water the tube was to be flushed. In an interview on 04/25/18 at 10:02 AM, the DON said the resident's care plan should be individualized for the resident and specify interventions needed to provide care based on orders and resident's needs. The DON agreed the care plan should include the caloric value of the tube feeding, the mechanism of administration, and when to flush the tube, as well as the amount of water to use to flush. On 04/26/18 at 09:23 AM, an interview with the Roving CRC (Clinical Reimbursement Coordinate responsible for developing and revising care plans), revealed Resident #128's care plan should have included the mechanism of administration, caloric value of the ordered tube feeding, and the specific way to flush the tube. The Roving CRC said the current plan would be revised to include individualized and person-specific interventions.",2020-09-01
652,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,657,D,0,1,FJW311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to revise the care plans for three (3) of thirty-one (31) residents reviewed. Resident #109's care plan was not revised after a palm guard to prevent ADL (activities of daily living) decline was discontinued. Resident #80's care plan was not revised to include care/treatment for [REDACTED]. Resident #402's care plan was not revised to include the use of oxygen. Resident identifiers: #109, #80, and #402. Facility census: 156. Findings included: a) Resident #109 Review of the resident's care plan found a focus/problem of, Resident is at risk for decline in ADL's (activities of daily living) related to compromising functional ability. The goals associated with the problem were: - Resident will continue to feed self independently after set up through next review. - Resident will continue to participate in ADL care through next review. Interventions included: - Patent to wear right palm guard from 2:00 p.m. to 8:00 a.m. (MONTH) remove for hygiene. Remove and perform skin check every shift, however, (Name of Resident) is not compliant with wearing palm guard. At 10:12 a.m. on 04/24/18, the Director of Nursing (DON) confirmed the palm guard was discontinued on 03/13/18. b) Resident #80 Observation on 04/23/18 at 3:40 p.m. found this resident lying in bed. He had contractures of both hands. There were no splints, palm guards, or any type of device in place to either hand. On 04/24/18 at 10:30 a.m., observations found he held both hands firmly closed. There were no splints, palm guards, rolled washcloths, or any devices in either hand. An observation at 12:15 p.m. on 04/24/18, accompanied by Registered Nurse Employee #13 (E#13), found a white washcloth placed partially in his left hand, and a thin, smaller, yellow-colored cloth was placed partially in his right hand. When asked whether the cloths were placed in his hands later than 10:45 a.m. that morning, E#13 replied in the affirmative and said she had placed them. On 04/24/18 at 12:15 p.m., E#13 removed the cloths in preparation for inspection of the palms of both hands. When the nurse removed the cloths from his hands, a foul-smelling odor was immediately noted. When asked if the foul odor came from the cloths that were in his hands, E#13 stated I can't put my nose on them to smell them. E#13 tried to move the resident's contracted fingers so the palms could be visualized. His fingers were drawn down tightly, which made visualization of the palms inadequate. She moved the resident's right thumb about one-quarter of an inch outward, which then allowed visualization of a dry, reddened area on the skin of the fourth finger of the right hand. The thumbnail of the right hand lay directly on top of, and pressing against the described reddened area of the fourth finger. The right thumbnail was smooth, but long. It protruded beyond the flesh at the tip of the thumb a quarter of an inch. It needed trimmed. At 3:15 p.m. on 04/24/18 occupational therapist Employee #171 and wound nurse/registered nurse E#120 came to the resident's bed. A white washcloth and a thinner yellow cloth lay on his chest. The resident's palms could only be visualized partially. E#120 said they were aware of the reddened area to the right fourth finger and were monitoring and treating it. He said the right thumbnail needed trimmed. Observation on 04/25/18 at 2:25 p.m., accompanied by licensed nurse Employee #80 (E#80) found no cloths, palm guards, or any devices in either hand. When asked why there was no padding or cloth between the thumbnail and the fourth finger of the right hand to reduce pressure, she then attempted to thread the yellow cloth into the resident's right hand. She ensured it padded the skin between the right thumbnail and the reddened area to the fourth finger beneath it. The thumbnail of the right hand was still long as previously noted. The nurse agreed the thumbnail was too long. She said she had some clippers and would cut and trim the thumbnail. The nurse also attempted to place a washcloth in the palm of the resident's left hand. Review of grievances on 04/24/18 at 4:00 p.m. found one from the daughter of Resident #80 dated 02/19/18. It stated, Daughter concerned resident's hands are not being cleaned and nails aren't being clipped as often as they should be. The corrective action from Unit 3 Nursing Staff stated, Ordered hands to be cleaned daily and nails trimmed every Tuesday and Friday. Review of the (MONTH) Medication Administration Record [REDACTED]. The (MONTH) MAR indicated [REDACTED]. Staff initialed its completion on 03/06/18 and 03/09/18. The space for 03/13/18 was left blank. This too, was on the MAR for one (1) week. Review of the resident's care plan on 04/24/18 at 4:00 p.m. found an area of focus for the resident being dependent for ADL care as evidenced by multiple contractures. A goal included that he would be clean, dry and odor free through next review. The care plan was not fully developed/revised to include cleaning his hands daily and/or how to accomplish that task. The care plan was not fully developed/revised about the need for nail trimming as it related to the pressure of the thumbnail cutting into the contracted fourth finger beneath it. The care plan included an intervention for staff to use palm guards. Observations found no use of the palm guard on either hand. During an interview with the director of nursing (DON) on 04/25/18 at 6:00 p.m., she said there should not have been an odor to the hand as it was possible to clean his hands. She acknowledged that the care plan was not revised to address the special needs for cleaning his hands and trimming of his nails following the grievance filed on 02/19/18. During this interview, it was also discussed that the care plan directed staff to use a palm guard, although it was not being used. She agreed the resident's care plan should have been revised related to mobility and the positioning needs of his contracted hands, as he no longer used the palm guard. On 04/26/18 at approximately 9:30 a.m., these findings discussed shared with the administrator. No further information was provided by the facility prior to exit. c) Resident #402 On 04/16/18, Resident #402 was ordered oxygen 28% via [MEDICAL CONDITION] collar as needed. Resident #402's comprehensive care plan included an intervention for oxygen 45% via heated [MEDICAL CONDITION] collar. During an interview on 04/24/18 at 11:29 a.m., the Center Nurse Executive (CNE) agreed the intervention on Resident #402's comprehensive care plan for oxygen 45% via heated [MEDICAL CONDITION] collar was not current. The CNE agreed the intervention needed revised to oxygen 28% via [MEDICAL CONDITION] collar as needed.",2020-09-01
653,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,677,G,0,1,FJW311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, and staff interview, the facility failed to provide activities of daily living (ADL) care for three (3) of nine (9) residents reviewed for ADL care. The failure to ensure dependent residents received needed care and services resulted in actual harm for Resident #26. Resident #26 did not receive care needed care for her hands, resulting in a Stage II pressure area on her palm and pain when attempts were made to open her hand. The facility's failure to ensure Resident #119 received needed skin care and prompt incontinence care were determined to result in actual harm to this resident as he developed pressure ulcers and painful excoriation. Resident #80 needed hygienic measures for hand contractures. Resident identifiers: #80, #26, and #119. Facility census: 156. Findings included: a) Resident #26 Observation of the resident at 4:45 p.m. on 04/23/18, found the resident's left and right hands appeared contracted. The resident had no splinting devices in use. Review of the resident's current care plan found the following focus/problem: - Resident requires assistance with ADL's (activities of daily living) due to limited mobility. The goal associated with the problem: - Residents/Patients ADL care needs will be anticipated and met throughout the next review period. Interventions included: - Monitor for decline in ADL function. Refer to rehabilitation therapy and decline in ADL's is noted. Provide resident extensive assist for bed mobility, dressing, eating, personal hygiene, and grooming. While investigating to determine why the resident had possible contractures without splinting devices the following observations were made: - Observation of the resident at 1:44 p.m. on 04/25/18, with OT #171 revealed, OT #171 was able to open the resident's right hand with without difficulty. When opened, a sour odor, coming from the resident's right hand was evident. OT #171 said she had sinuses and could not smell the odor. When OT #171 attempted to open the resident's left hand, a strong putrid, foul smelling, sour odor, emanated from the hand. OT #171 acknowledged she could smell the odor coming from the left hand. OT #171 said she would get staff to clean the resident's hands. OT #171 was unable to fully extend all the fingers of the resident's left hand. The ring finger was pressed into the palm of the resident's hand. It was evident the finger nailwas cutting into the palm of the resident's hand. OT #171 said, She was never like this when we finished with therapy services in January. When OT #171, discarded her gloves in the trash can in the corner of the resident's room, the foul odor from the gloves could be smelled coming out of the trash can. Throughout the observation, the resident said, Ouch, that hurts, that hurts, when OT #171 was attempting to work with the resident's left hand. The resident also said, I need my fingernails cut, the doctor said so. The resident nails were long jagged and unclean. These observations were discussed with the director of nursing (DON) at 2:00 p.m. on 04/25/18. The DON said she would have a nurse soak the resident's hand in warm water, assess the condition of the hands and cut the fingernails. At 2:15 p.m. on 04/25/18, Licensed Practical Nurse (LPN) #26 was observed cleaning the resident's hands and cutting the fingernails. LPN #26 acknowledged the resident had a foul smelling odor coming from both hands. LPN #26 said she thought she could see a, break in the skin, on the palm of the left hand. She said, I won't know for sure until I soak the hand and get it to open a little more. At 3:15 p.m. on 04/25/18, the director of rehabilitation services, Employee #170 said the resident was screened for services on 04/19/18. [NAME] #170 said, When we screen a resident we can't touch them. If the patient can't tell us what is wrong or the staff don't tell us we don't know. She said the resident didn't want any therapy but did agree to a speech evaluation. E#170 said staff would not have looked at the resident's hands. At 3:17 p.m. on 4/25/18, the information received from E#170 was discussed with the DON. The DON said she was unaware a therapist could not touch a resident during a screen. At 8:10 a.m. on 04/26/18, observation with the DON found the DON confirmed the resident had a Stage II pressure area on the left hand, just under the ring finger on the palm of left hand. The DON acknowledged the resident still had a slight sour odor coming from the left hand. At 8:35 a.m. on 004/26/18, the DON said, I am taking care of this, calling the doctor, the residents family and will get an order for [REDACTED]. The DON acknowledged staff had not been cleaning the resident's hands as needed to prevent the odor. The DON said the skin check, completed by the nursing staff on 04/20/18, should have caught the problem. The DON was unable to provide any information to support the facility was aware of the foul odor of the resident's hands, the left hand contracture, or the development of a Stage II pressure area on the palm of the resident's left hand, prior to surveyor intervention. The failure to provide extensive assistance for personal hygiene, (ADL care and cleaning) of the residents hands lead to the foul odor coming from both the left and right hands. Had ADL care been provided, the facility may have recognized the inability of the resident to voluntarily open both the left and right hands. Had the facility addressed this decline, the contracture of the left hand may have been prevented. The failure to address the resident's contracture of the left hand lead contributed to the development of a Stage II pressure ulcer to the left hand. This was determined to constitute actual harm to this resident. b) Resident #119 During the screening for the initial pool of the Long-Term Care Survey Process, an interview on 04/23/18 at 11:37 AM with Resident #119 revealed he had a pressure ulcer on his lower buttock from sitting in urine for 30 minutes or longer. He went on to explain he could not walk, and tried to use a urinal, but sometimes did not get all the urine in the urinal. He stated there was not enough staff last night - one aide was with two (2) nurse aides in training. According to the resident, it takes more than an hour for staff to answer a call light. He said he had been told his aide was on break, and the aides also told him they were short staffed. This was mostly on the 3:00 PM to 11:00 PM or the 11:00 PM to 7:00 AM shifts. On 04/25/18 at 9:15 AM, Resident #119 was emotional and tearful saying that he was chewed out by the Nurse Aide #96 for calling the nurses' station with his cell phone. He stated she told him to only use his call light, that was what it was for, and not to call the nurses' station again. He said, NA #96 told him that he was not the only one on this floor and he just needed to wait his turn. He said he responded by telling her he used the call light and had been waiting for more than 30 minutes before he called the nurses' station with his cell phone, because his skin was on fire from sitting in urine. The resident told this to the surveyor, Wound Care Nurse #120, and Nurse Aide #84. On 04/25/18 at 9:15 AM, Wound Care Nurse #120 agreed to do a complete skin assessment with the surveyor present. A complete skin audit by Wound Care Nurse #120 found: - 1. Pressure Ulcer Stage II on Coccyx - 2. Pressure Ulcer Stage II on right ear - 3. Excoriated areas bilateral groin, under both breast, bilateral abdominal folds, bilateral upper outer thighs and bilateral calf's. - 4. Reddened area to the right great toe, second and third toes, right heel. The failure of the facility to ensure needed skin care and prompt incontinence care were determined to result in actual harm to this resident. During an interview on 04/25/18 at 9:45 AM, when informed of findings, the DoN stated she had heard from Wound Care Nurse #120 and was addressing the problem. On 04/25/18 at 1:10 PM, Resident #119 said that he was still upset over the NA #96 fussing at him that morning and it was not the first time he has had to wait for over 30 minutes for assistance. He went on to say he has called his wife many times to have her call the facility to ask them to help him. c) Resident #80 Observation on 04/23/18 at 3:40 p.m. found this resident lying in bed. He had contractures of both hands. There were no splints, palm guards, or any type of device in place to either hand. Observations on 04/24/18 at 10:30 a.m., again found he had no splints, palm guards, rolled washcloths or any devices in either hand. He held both hands firmly closed. At 12:15 p.m. on 04/24/18, while accompanied by Registered Nurse Employee #13 (E#13), a white washcloth was found placed partially in his left hand, and a thin, smaller, yellow-colored cloth was was found placed partially in his right hand. When asked whether these cloths were placed in his hands later than 10:45 a.m. that morning, E#13 replied in the affirmative and said she had placed them. On 04/24/18 at 12:15 p.m., E#13 removed the cloths in preparation for inspection of the palms of both hands. When the nurse removed the cloths from his hands, a foul smell was immediately noted. When asked if that foul odor came from the cloths having been placed in his hands, E#13 stated I can't put my nose on them to smell them. E#13 tried to move the contracted fingers so the palms could be visualized. His fingers were drawn down tightly, which made visualization of the palms inadequate. She moved the right thumb about one-quarter of an inch outward, which then allowed visualization of a dry, reddened area on the skin of the fourth finger of the right hand. The thumbnail of the right hand lay directly on top of, and pressing against, the reddened area of the fourth finger beneath it. The right thumbnail was smooth, but long, protruding beyond the flesh at the tip of the thumb a quarter of an inch. It needed trimmed. At 3:15 p.m. on 04/24/18, Occupational Therapist Employee #171 and wound nurse/registered nurse E#120 came to the resident's bed. A white wash cloth and a thinner, yellow cloth lay on his chest. The palms could only slightly be visualized. E#120 said they were aware of the reddened area to the right fourth finger and were monitoring and treating it. He said the right thumbnail needed trimmed. Review of a grievance on 04/24/18 at 4:00 p.m. found one from the daughter of Resident #80 dated 02/19/18. It stated Daughter concerned resident's hands are not being cleaned and nails aren't being clipped as often as they should be. The corrective action from Unit 3 Nursing Staff stated Ordered hands to be cleaned daily and nails trimmed every Tuesday and Friday. Review of the (MONTH) Medication Administration Record [REDACTED]. This was a one (1) week audit. The (MONTH) MAR indicated [REDACTED]. Staff initialed its completion on 03/06/18 and 03/09/18. The space for 03/13/18 was left blank. This, too, was on the MAR for one (1) week. Review of the resident's care plan on 04/24/18 at 4:00 p.m., found an area of focus for the resident being dependent for ADL care as evidenced by multiple contractures. A goal included that he would be clean, dry and odor free through next review. The care plan was not fully developed to include cleaning his hands daily and/or how to accomplish that task, or anything about nail trimming. Observation on 04/25/18 at 2:25 p.m., accompanied by licensed nurse Employee #80 (E#80) found no cloths, palm guards or any devices in either hand. When asked why there was no padding or cloth between the thumbnail and the fourth finger of the right hand to reduce pressure, she threaded the yellow cloth into the resident's right hand. She ensured it padded the skin between the right thumbnail and the reddened area to the fourth finger beneath it. The nurse agreed the right thumbnail was too long. She said she had some clippers and would cut and trim that offending right thumbnail. The nurse also placed a washcloth in the palm of the left hand. During an interview on 04/25/18 at 6:00 p.m. , the director of nursing said there should not have been an odor from the palms of his hands as it was possible for staff to clean his hands. She was informed that the nurse on 04/24/18 at 3:15 p.m. stated his right thumbnail was too long, and that they were monitoring and treating the reddened skin area to the right fourth finger upon which the right thumb and thumbnail rested. She was also informed that the following day on 04/25/18 at 2:25 p.m. the right thumbnail was still long and in need of trimming. The nurse on duty at 2:25 p.m. on 04/25/18 said she had clippers and would trim the thumb nail right away. A copy of the grievance form dated 02/19/18 conveyed the resident's daughter's concern that his hands were not cleaned and his nails not clipped as often as they should be. The DON acknowledged the grievance. No further information was provided prior to exit. On 04/26/18 at approximately 9:30 a.m., these findings were discussed with the administrator. No further information was provided by the facility prior to exit.",2020-09-01
654,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,684,G,0,1,FJW311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, staff interview, record review, and observation, the facility failed to ensure one (1) of thirty-one (31) residents reviewed receive care and services in accordance with the comprehensive assessment and plan of care. Resident #147 did not receive insulin as directed by the physician which lead to harm due to critically elevated blood glucose levels, high sodium levels, and acute kidney injury. Additionally, there was no evidence of an assessment of the resident's mental and physical status when his blood sugars were over 600. Furthermore, the resident's antibiotic was stopped prior to completion of the course ordered by the physician, but there was no evidence the physician had ordered it discontinued. Resident identifier: #147. Facility census: 156. Findings included: a) Resident #147 1. An interview with the resident and his daughter at 11:19 a.m. on 04/23/18, found the daughter was very worried about the medical condition of her father. The daughter said her father had been very confused, his blood sugars were high, he had an incontinent episode, and he had a cough. She said her father was recently diagnosed with [REDACTED]. She was fearful he would die if something was not done. She said she talked to someone of Saturday, a nurse she thought, who said she would have to wait until Monday to see the doctor. She said the facility did get a chest x-ray, but she did not think this would tell them if he was having other problems. She believed her father needed to have some blood work and hoping that was going to happen that day. Record review found a [AGE] year-old male resident admitted to the facility on [DATE]. His hospital discharge summary noted the resident was hosptalized on [DATE]. He was treated for [REDACTED]. ANCA (associated small-vessel vasculitis) are autoantibodies produced by a person's immune system that mistakenly attack proteins within the person's [DIAGNOSES REDACTED]s (white blood cell types). The most common subsets of ANCA are those that target the proteins myeloperoxidase (MPO) and proteinase.) The resident was discharged from the hospital to the nursing home on 03/28/18. Review of the resident's medical record found he was seen by the family nurse practitioner (FNP) on Saturday, 04/20/18 for a change in condition. The FNP noted, Chief Complaint / Nature of Presenting Problem: [DIAGNOSES REDACTED], family concerned regarding cough History of Present Illness: The patient is a [AGE] year old male with known history of [MEDICAL CONDITION] and confusion. Patient reports feeling well. Does seem more lethargic today. Daughter reports patient has been coughing and she is worried he has pneumonia as 'this is how it starts, when he looks, lost,' nurse at bedside check patient's blood glucose for noon and BG (blood glucose) was 50. Patient did eat breakfast this morning staff relates. The plan for treatment was: 1. [MEDICATION NAME] decreased to 5 units TID (3 times a day) with meals 2. [MEDICATION NAME] decreased to 20 units QHS (every hour of sleep/bedtime) 3. patient was given lunch, and order to recheck blood glucose one hour after lunch, to notify provider if remains low after a meal orders discussed with nursing A handwritten physician's orders [REDACTED]. Check BMG (a small protein and is readily reabsorbed by kidneys with normal function) 1 hour after lunch due to [DIAGNOSES REDACTED] decrease [MEDICATION NAME] to 20 units QHS decrease insulin [MEDICATION NAME] to 5 units TID (3 times a day) with meals for [DIAGNOSES REDACTED]. Review of the resident's Medication Administration Record [REDACTED] -- The [MEDICATION NAME] was not decreased to 20 units as directed by the physician on 04/20/18. -- The [MEDICATION NAME] was discontinued and was not given at all, until Monday 04/23/18. The resident's blood glucose readings were: - On 04/21/18: BG (Blood Glucose) was 312 at 7:30 a.m. BG 171 at 11:30 a.m. BG 357 at 4:30 p.m. - On 04/22/18: BG 384 at 7:30 a.m. BG 396 at 11:30 a.m. BG 253 at 4:30 p.m. On 04/23/18 at 6:30 a.m., the resident's blood glucose was so high, the facility was unable to obtain a reading. The nurse's note, dated 04/23/18 at 6:37, noted the resident's blood glucose level was over 600. The resident's physician was contacted and ordered, Humalog 10 units now. Recheck glucose in 1 hours. If glucose is higher than 400 repeat 1 dose. At 7:30 a.m. on 04/23/18, the MAR indicated [REDACTED]. Another 10 units of Humalog was administered. At 8:30 a.m. on 04/23/18, the resident's blood glucose was still 511. At 9:40 a.m. on 04/23/18 another 15 units of Humalog was administered, according to the MAR. Nursing staff contacted the physician for this order. A nursing note written at 12:06 a.m. on 04/23/18, noted the physician was contacted and another 20 units of [MEDICATION NAME] was given and the physician said to give the [MEDICATION NAME] that is due tonight. The MAR indicated [REDACTED] There were no nursing notes describing the resident's condition when his blood glucose was above 600; such as was the resident level of consciousness affected, was he thirsty, tired, was his coordination affected, etc. The resident was seen by the physician on 04/23/18 at 7:35 p.m. The plan ordered by the physician: Stat (immediately) labs came back. WBC (white blood cell count) is normal. But BUN/CR (blood urea nitrogen/creatinine ratio) significantly increased from prior. K (potassium) is 5.7. Patient in AKI (acute kidney injury), ordered IVF (intravenous fluids), hold [MEDICATION NAME] and [MEDICATION NAME], give [MEDICATION NAME] for [MEDICAL CONDITION] (high potassium). Recheck BMP (basic metabolic panel) in morning, the low sodium on BMP is due to high BG of over 700. The BG has been checked since then and it is down to 200's no longer in 700's. At 8:40 a.m. on 04/25/18, the director of nursing (DON) was interviewed regarding Resident #147. Before the interview began, the DON said, I already know a medication error was made regarding the physician's orders [REDACTED]. The DON verified the [MEDICATION NAME] was to be decreased to 20 units due to the resident's low blood glucose level of 50 obtained on 04/20/18. She said the new order was transcribed to the MAR, but was then discontinued. The resident never received any [MEDICATION NAME] and the resident's blood glucose levels were above 600, 3 days after the medication was stopped when it should have been reduced. The DON verified the blood glucose level was not obtained after the [MEDICATION NAME] was administered at 11:00 a.m. on 04/24/18. The DON said she had already disciplined the staff involved in the medication errors. The DON confirmed the medication error resulted in treatments that could have been prevented if staff had followed the physician's orders [REDACTED]. The failure to administer insulin as ordered by the physician and to monitor the resident's blood glucose when indicated resulted in actual harm to this resident. 2. On 04/02/18 the physician ordered [MEDICATION NAME] 1 gram IM (intramuscular) daily for the next 4 days, pending the results of the urinalysis. Review of the resident's Medication Administration Record [REDACTED]. There was no explanation why the medication was discontinued, and no evidence the physician was contacted and approved the discontinuation. At 9:21 a.m. on 04/25/18, the DON said the results of the urinalysis showed the resident did not have a urinary tract infection. She said the nursing staff should have documented the physician was contacted and the staff should have obtained an order to discontinue the [MEDICATION NAME].",2020-09-01
655,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,686,G,0,1,FJW311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, staff interview, review of facility policy, and observations, the facility failed to provide appropriate care and services to prevent pressure ulcers and failed to identify pressure ulcers after they developed for two (2) of five (5) residents reviewed for the care area of pressure ulcers. Resident #119, a dependent individual, who was known to be at risk of pressure ulcer development, did not receive incontinence care in a timely manner and did not have accurate assessments of his skin condition. Resident #26, also dependent and known to be at risk of pressure ulcer development, did not receive interventions to prevent a pressure ulcer from developing on her hand. The findings for these two (2) residents led to a determination that both had experienced actual harm as a result of the facility's failure to provide needed care and services. Resident Identifiers: #119 and #26. Facility census:156. Findings included: a) Resident #119 During the Long-Term Care Survey Process screening, on 04/23/18 at 11:37 AM, Resident #119 stated he had a pressure ulcer on his buttock from sitting in urine for 30 minutes or longer. He explained he tried to use a urinal, but sometimes he did not get all the urine in the urinal. Medical record review identified he scored 15 on the Brief Interview for Mental Status, indicating he was cognitively intact. His [DIAGNOSES REDACTED]. There was no mention of current pressure ulcers found in the resident's record. Review of Skin Check Performed Sheets dated from 1/27/18 to 4/23/18 found the following documentation: - 01/27/18 - No Skin Injury/Wounds by Licensed Practical Nurse (LPN) #172 - 02/04/18 - No Skin Injury/Wounds by LPN #92 - 02/10/18 - No Skin Injury/Wounds by LPN #172 - 02/17/18 - No Skin Injury/Wounds by LPN #92 - 02/24/18 - No Skin Injury/Wounds by LPN #172 - 03/03/18 - No Skin Injury/Wounds by LPN #92 - 03/10/18 - No Skin Injury/Wounds by LPN #172 - 03/17/18 - Yes Skin Injury/Wounds identified No New Skin Injury/Wounds Type of Skin Injury/Wounds Moisture Associated Skin Damage by Registered Nurse (RN) #4 - 03/24/18 - No Skin Injury/Wounds by LPN #172 - 04/02/18 - No Skin Injury/Wounds by RN # 4 - 04/07/18 - No Skin Injury/Wounds by LPN # 33 - 04/23/18 - No Skin Injury/Wounds by LPN # 92 Review of the resident's annual minimum data set (MDS) assessment, with an assessment reference date or 03/28/18 found the resident was identified as being at risk for pressure ulcer development, that he was frequently incontinent of bowel and bladder, and required the extensive assistance of 2 or more staff for personal hygiene. The assessment had triggered for pressure ulcers and was marked to indicate it would be care planned. On 04/25/18 at 9:15 AM, Wound Care Nurse #120 agreed to do a complete skin assessment with the surveyor observing. With the resident's permission, Wound Care Nurse #120 pulled the sheets back and found a very large red excoriation on the resident's upper outer thighs. Further examination identified broken skin under his scrotum and on his coccyx. The resident's tee shirt was saturated with urine up his back and had small amount of stool on the bottom of the shirt. According to the resident, Nurse Aide (NA) #96 had changed him earlier, therefore the nurse aide left him like this. Wound Care Nurse #120 removed the tee shirt. Wound Care Nurse #120 asked Resident #119 how long had his skin been in that condition? The resident responded a year, that it had started after being on this floor for a week. During an interview on 04/25/18 at 9:35 AM, Wound Care Nurse #120 stated he was just mortified by what was just discovered, referring to the condition of Resident #119's skin. He went on to say he had no excuse and they had failed this resident. On 04/25/18 at 9:45 AM, when informed of the findings for Resident #119, the director of nursing (DoN) stated she was aware of the problem and was working on a plan of correction. The results of the complete skin audit provided by Wound Care Nurse #120 were: 1. Pressure Ulcer Stage II on Coccyx 2. Pressure Ulcer Stage II on right ear 3. Excoriated areas bilateral groin, under both breast, bilateral abdominal folds, bilateral upper outer thighs and bilateral calf's. 4. Reddened area to the right great toe, second and third toes, right heel. Resident #119's care plan, initiated on 04/03/17, identified the resident had impaired skin integrity due to his psoriasis and Moisture Associated Skin Damage (MASD). A history of pressure ulcers was noted. The interventions for this problem included: - Monitor skin for signs/symptoms of skin breakdown i.e. - Observe skin condition with ADL care daily and report abnormalities - Skin check per policy - Weekly skin assessment by license nurse - Weekly wound assessment The facility's policy, NSG236 Skin Integrity Management, Effective date 07/01/01, Revision date 11/28/16, included staff were to continually observe and monitor for skin changes and implement revisions to the plan of care. The purpose was to provide safe and effective care to prevent the occurrence of pressure ulcers and promote healing of all wounds. The failure of the facility to assess and monitor this resident who was identified as at risk of pressure ulcer development, had triggered pressure ulcers on his annual MDS, had multiple risk factors for pressure ulcer development, and failure to follow/implement its own policy, resulted in actual harm to this resident. b) Resident #26 Observation of the resident at 4:45 p.m. on 04/23/18, found both the resident's left and right hands appeared contracted. The resident had no splinting devices in use. When asked if the resident could open her hands, the resident's nurse aide (NA), NA #149, said, she could open one hand but, I would probably break her fingers if I tried to open the other hand, and I'm not going to do that. NA #149 said the resident's left hand would not open. She was not sure how long the resident had been unable to open her left hand. Review of the medical record at 11:30 a.m. on 04/25/18, found the resident had no orders for any splinting devices to either hand. The most recent minimum data set (MDS), a quarterly, with an assessment reference date (ARD) of 01/25/18, noted the resident did not have any contractures and did not have any pressure areas. Review of the current care plan found no reference to any contractures or pressure wounds. At 1:41 p.m. on 04/25/18, the occupational therapist (OT), OT #171 said the resident had received occupation therapy and was discharged from OT on 01/26/18. When we discharged her, she didn't have any hand contractures, she didn't need any interventions. Observation of the resident at 1:44 p.m. on 04/25/18, with OT #171 revealed the following: OT #171 was able to open the residents right hand with without difficulty. When opened, a sour odor, coming from the right hand was evident. OT #171 said she had sinuses and couldn't smell the odor. When OT #171 attempted to open the left hand, a strong putrid, foul smelling, sour odor, radiated from the left hand. OT #171 did acknowledge she could smell the odor coming from the left hand. OT #171 said she would get staff to clean the resident's hands. OT #171 was unable to fully extend all the fingers of the left hand. The ring finger was pressed into the palm of the resident's hand. It was evident the fingernail was cutting into the palm of the resident's hand. OT #171 said, She was never like this when we finished with therapy services in January. When OT #171, discarded her gloves in the trash can in the corner of the resident's room, the foul odor from the gloves could be smelled coming out of the trash can. Throughout the observation, the resident said, Ouch, that hurts, that hurts, when OT #171 was attempting to work with the resident's left hand. The resident also said, I need my fingernails cut, the doctor said so. The resident nails were long jagged and unclean. These observations were discussed with the director of nursing (DON) at 2:00 p.m. on 04/25/18. The DON said she would have a nurse soak the resident's hands and assess the resident to determine if the resident has a pressure ulcer to the palm of her left hand. Further review of the electronic medical record found a physician's progress note, dated 04/16/18. The physician did not note the resident's contracture of her left hand or any pressure ulcers. A skin check by facility nursing staff on 04/13/18 at 4:00 p.m. had no skin injury/wounds noted. At 2:15 p.m. on 04/25/18, Licensed Practical Nurse (LPN) #26 was observed cleaning the resident's hands and cutting her fingernails. The nurse acknowledged there was a foul odor coming from both of the resident's hands. LPN #26 said she thought she could see a, break in the skin, on the palm of the left hand. She said, I won't know for sure until I soak the hand and get it to open a little more. At 8:10 a.m. on 04/26/18, during an observation of the resident with the DON, she confirmed the resident had a Stage II pressure on her left hand, just under the ring finger on the palm of her left hand. The DON further confirmed the facility was unaware of the pressure ulcer prior to surveyor intervention. At 8:35 a.m. on 04/26/18, the DON said, I am taking care of this, calling the doctor, the residents family and will get an order for [REDACTED]., probably at least a month or longer, it would be hard to say. The DON said she was unaware of the situation and had no evidence to present to verify any interventions were implemented, such as even using a rolled washcloth in the resident's hands to prevent the fingernails from digging into the skin which lead to the development of the resident's pressure ulcer. The DON confirmed the skin check, completed by the nursing staff on 04/20/18, should have caught the problem. Review of the resident's minimum data set (MDS) assessments, found this [AGE] year-old female resident was assessed as at risk of pressure ulcer development and as requiring extensive assistance for activities of daily living since admitted on [DATE]. The resident's most recent assessment, a quarterly MDS with an assessment reference date of 01/25/18, identified she weighed 99 pounds and had functional impairment of both upper extremities. The facility failed to ensure this dependent resident, who was known to be at risk for pressure ulcers and had limitations in the use of her upper extremities, received needed care and services to prevent an avoidable Stage II pressure ulcer in her left hand. These finding led to a determination actual harm.",2020-09-01
656,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,688,G,0,1,FJW311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, and record review, the facility failed to ensure four (4) of five (5) residents reviewed for positioning and mobility received appropriate treatment and services to prevent a decrease in range of motion. The facility failed to recognize Resident #26's range of motion in her hands was declining. The facility failed to provide interventions (services, care and equipment) for Resident #26 to address the decrease in range of motion. The failure to provide care lead to the development of a pressure ulcer to the palm of the Resident's left hand and pain when attempts were made to open her hand. This was determined to constitute actual harm for Resident #26. In addition, the facility failed to provide care for Resident #99 and Resident #80 who had decreases in range of motion. Resident #62 did not receive restorative nursing services as ordered by the physician. Resident identifiers: #26, #80, #99, and #62. Facility census: 156. Findings included: a) Resident #26 Observation of the resident at 4:45 p.m. on 04/23/18, found the resident's left and right hands appeared contracted. The resident had no splinting devices in use. When asked whether the resident could open her hands, the resident's nurse aide (NA), NA #149, said, I can open one hand, but I would probably break her fingers if I tried to open the other hand, and I'm not going to do that. NA #149 said the left hand would not open. She was not sure how long the resident had been unable to open that hand. Review of the medical record at 11:30 a.m. on 04/25/18, found the resident had no orders for any splinting devices for either hand. The most recent minimum data set (MDS), a quarterly assessment, with an assessment reference date (ARD) of 01/25/18, noted the resident did not have any contractures, nor did she have any pressure areas identified. Review of the resident's current care plan found no reference to any contractures. The care plan did include a focus/problem of, Resident requires assistance with ADL's (activities of daily living) due to limited mobility. The goal associated with the problem was, Residents/Patients ADL care needs will be anticipated and met throughout the next review period. Interventions included: - Monitor for decline in ADL function. Refer to rehabilitation therapy and decline in ADL's is noted. - Provide resident extensive assist for bed mobility, dressing, eating, personal hygiene, and grooming. At 1:41 p.m. on 04/25/18, the occupational therapist, OT #171, said the resident had received occupation therapy and was discharged from OT on 01/26/18. When we discharged her, she didn't have any hand contractures, she didn't need any interventions. Observation of the resident at 1:44 p.m. on 04/25/18, with OT #171 revealed OT #171 opened the resident's right hand without difficulty. When opened, a sour odor, coming from the right hand was evident. OT #171 said she had sinuses and could not smell the odor. When OT #171 attempted to open the left hand, a strong putrid, foul smelling, sour odor, emanated from the resident's left hand. OT #171 did acknowledge she could smell the odor coming from the left hand. OT #171 said she would get staff to clean the resident's hands. OT #171 was unable to fully extend all the fingers of the left hand. The ring finger was pressed into the palm of the resident's hand. It was evident the fingernail was cutting into the palm of the resident's hand. OT #171 said, She was never like this when we finished with therapy services in January. When OT #171, discarded her gloves in the trash can in the corner of the resident's room, the foul odor from the gloves could be smelled coming out of the trash can. Throughout the observation, the resident said, Ouch, that hurts, that hurts, when OT #171 was attempting to work with the resident's left hand. The resident also said, I need my fingernails cut, the doctor said so. The resident nails were long jagged and unclean. These observations were discussed with the director of nursing (DON) at 2:00 p.m. on 04/25/18. The DON said she would have a nurse soak the resident's hands and assess the resident to determine if the resident had a pressure ulcer to the palm of her left hand. Further review of the electronic medical record found a physician's progress note dated 04/16/18. The physician did not address any issues regarding the resident's hands. The physician addressed only mild contracture of the resident's legs. The physician's plan: She is at last stage of life, will consider referring to hospice if MPOA (medical power of attorney) agrees. The physician did not note any contractures of the resident's left hand or any pressure ulcers. The skin check performed by facility nursing staff on 04/13/18 at 4:00 p.m. had no skin injuries/wounds noted. Observations noted Licensed Practical Nurse (LPN) #26 cleaning the resident's hands and cutting her fingernails at 2:15 p.m. on 04/25/18. LPN #26 acknowledged there was foul smelling odor coming from both of the resident's hands. LPN #26 said she thought she could see a, break in the skin, on the palm of the left hand. She said, I won't know for sure until I soak the hand and get it to open a little more. At 3:15 p.m. on 04/25/18, Employee #170, the director of rehabilitation services, said the resident was screened for services on 04/19/18. [NAME] #170 said, When we screen a resident we can't touch them. If the patient can't tell us what is wrong or the staff don't tell us we don't know. She said the resident did not want any therapy, but did agree to a speech evaluation. [NAME] #170 said the resident had no contractures of her hands when discharged from OT services on 01/26/18. The therapy screen dated 04/19/18 noted, Resident per staff (symbol for increased) confusion/resident is not out of bed compliance due to medical decline per resident does not want any therapy. However did agree to a ST (speech therapy) evaluation or further screen. At 3:17 p.m. on 4/25/18, when these findings were discussed with the DON, she said she was unaware a therapist could not touch a resident during a screen. At 8:10 a.m. on 04/26/18, during an observation of the resident with the DON, she confirmed the resident had a Stage II pressure on the left hand, just under the ring finger on the palm of the hand. The DON further confirmed the facility was unaware of the pressure ulcer prior to surveyor intervention. At 8:35 a.m. on 004/26/18, the DON said, I am taking care of this, calling the doctor, the resident's family and will get an order for [REDACTED]. When asked how long she would estimate the resident's left hand had been contracted, she replied, I don't know, probably at least a month or longer, it would be hard to say. The DON said she was unaware of the situation and had no evidence to present to verify any interventions were implemented, such as even using a rolled washcloth in the resident's hands to prevent the fingernails from digging into the skin which lead to the development of the resident's pressure ulcer. The DON confirmed the skin check, completed by the nursing staff on 04/20/18, should have caught the problem. The DON was unable to provide any verification the facility addressed the resident's contracted left hand before surveyor intervention. The facility failed to ensure the resident received ADL care which was evidenced by the foul odor of the resident's hands. Had ADL care been provided to the resident's hands, staff would have identified the developing contracture of the resident's left hand. The failure to address the developing contracture resulted in the resident experiencing pain when care was provided after the hand contracted, and resulted in a Stage II pressure ulcer. The failure to provide needed care for this resident constituted actual harm. b) Resident #80 Observation on 04/23/18 at 3:40 p.m. found this resident lying in bed. He had contractures of both hands. There were no splints, palm guards, or any type of device in place to either hand. Observation on 04/24/18 at 10:30 a.m. found him resting in bed with his eyes closed. No splints, rolled wash cloths, or palm guards were in place. He held both hands firmly closed. At 12:15 p.m. on 04/24/18, accompanied by E#13, observations noted a white washcloth placed partially in his left hand, and a thin, smaller, yellow-colored cloth was placed partially in his right hand. When asked whether the cloths were placed in the resident's hands after 10:45 a.m., E#13 replied in the affirmative and said she had placed them. E#13 tried to move the resident's contracted fingers so the palms could be visualized. His fingers were drawn down tightly, which made visualization of the palm inadequate. E13 could move the resident's right thumb about one-quarter of an inch outward, allowing visualization of a dry, reddened area on the skin of the fourth finger of the right hand. The thumbnail of the right hand lay directly on top of, and was pressing against the reddened area of the fourth finger. The right thumbnail was smooth, but long, protruding beyond the flesh of the tip of the thumb. At 3:15 p.m. on 04/24/18, E#171 and wound nurse/registered nurse E#120 went to the resident's bed. A white wash cloth and a thinner yellow cloth lay on his chest. E#120 said they were aware of the reddened area on the resident's right fourth finger and were monitoring and treating it. He said the right thumbnail needed trimmed. Review of the medical record on 04/24/18 found a physician's order dated 11/22/17 to place a clean wash cloth in the right palm (to separate the right thumb and right fourth finger) every shift related to contracture of muscle of the right hand. Review of the resident's care plan found an intervention on page 3 to use bilateral palm guards between 10:00 a.m. and 2:00 p.m. daily, and they could be removed for hygiene. On page 32, a problem of actual skin breakdown to the right fourth finger was noted. Interventions included to observe skin condition with activities of daily living (ADL) care daily and report abnormalities, provide wound treatment as ordered, and weekly skin assessments by the licensed nurse. The (MONTH) (YEAR) treatment administration record (TAR) contained a directive to place a clean washcloth in the resident's right palm (to separate the right thumb and right fourth finger) every shift related to contracture of the muscle. It contained another directive to apply no sting skin prep to the right fourth finger twice daily and prn (as needed). Observation on 04/25/18 at 9:10 AM found no cloths, palm guards, or any devices in either hand. Observation on 04/25/18 at 2:25 p.m., accompanied by licensed nurse Employee #80 (E#80) found no cloths, palm guards or any devices in either hand. When asked why there was no padding or cloth to the right hand, E#80 threaded the yellow cloth to the resident's right hand and ensured it padded the skin between the right thumbnail and the reddened area to the fourth finger of the right hand beneath it. The thumbnail of the right hand protruded about one-quarter of an inch beyond the top of the skin on the right thumb, and gouged into the fourth finger beneath. E#80 agreed the thumbnail was too long. She obtained some clippers, and said she would trim that offending right thumbnail right then. On 04/25/18 at 6:00 p.m., the director of nurse was informed that the nurse on 04/24/18 at 3:15 p.m. stated his right thumbnail was too long, and spoke awareness that they were monitoring and treating the reddened skin area to the right fourth finger upon which the right thumb and thumbnail rested upon. She was also informed that the following day, on 04/25/18 at 2:25 p.m., the right thumbnail was still long and in need of trimming. She was informed that although the physician ordered, and the TAR directed to place a clean washcloth in the right palm to separate the right thumb and right fourth finger, a cloth was not found in place during observations on 04/23/18, 04/24/18, and 04/25/18. The DON said the care plan should have been changed to delete the palm guard, as there is no physician's order for a palm guard. She said the physician's orders and the TAR orders should have been followed for the clean wash cloth in the right palm every shift related to contracture of the muscle. These findings were shared with the administrator on 04/26/18 at approximately 9:30 a.m. No further information was provided by the facility prior to exit. c) Resident #99 Observation on 04/23/18 at 12:00 p.m. noted the resident's left wrist was contracted, and her fingers curled into the palm of her hand. She wore no splint or device of any type to the left hand. Observation on 04/24/18 at 10:45 a.m., accompanied by registered nurse Employee #13 (E#13), found the resident wore no palm guard, had no rolled washcloth or any device for her left hand. E#13 gently stretched the fingers of the resident's left hand so the palm was visible. The resident had a partial thickness skin loss in the fold between the thumb and index finger of the left hand, that the nurse said she was unaware of this skin breakdown between the thumb and index finger of the left hand prior to this observation. Upon inquiry, the resident said she used to use a palm guard to the left hand, but thought someone took it. She said she would use it if she had it. When asked whether the resident ever used a rolled washcloth, or why she was not using a palm guard, E#13 said she thought the palm guard was discontinued. She said they used to place a rolled washcloth in the resident's left hand, but thought that therapy only used a rolled washcloth for certain hours of the day now. When asked whether she had used the rolled washcloth that day or the day before, the resident replied in the negative. During an interview with occupational therapist Employee #171 on 04/24/18 at 2:30 p.m., she said the resident's non-compliance over the years contributed to the contracture of her left hand. She said the resident was not agreeable with using the palm protector. She said the resident was agreeable with the rolled washcloth daily that could be removed for hygiene. She said the resident had it available night and day to help with skin integrity and to prevent worsening of the contracture. Medical record review on 04/24/18 also found that the (MONTH) treatment administration record (TAR) contained a directive to use the hand roll to the left hand from 8:00 a.m. to 12:00 noon daily. Nursing staff initialed its use 03/01/18 daily until 03/21/18 when she was admitted to the hospital. The (MONTH) (YEAR) TAR, reviewed on 04/24/18, contained no mention of any type of treatment modality for the contracted left hand. The resident's current care plan directed the resident have a hand roll in her left hand from 8:00 a.m. to 12:00 p.m. daily, and that it could be removed for skin checks and hygiene. This plan, initially created 11/08/17 and revised 04/05/18, included a goal for the resident to have no signs of skin breakdown through the next review. Observation on 04/25/18 at 9:00 a.m. found her asleep with no hand roll in her left hand. On 04/25/18 at noon the resident was awake and said she had not had the rolled cloth in her hand that day at any time. On 04/25/18 at 6:00 p.m., these findings were shared with the director of nursing (DON). These findings were shared with the administrator on 04/26/18 at approximately 9:30 a.m. No further information was provided by the facility prior to exit. d) Resident #62 On 10/12/17, the physician wrote an order for [REDACTED]. According to the Restorative Nursing Record, -- RNP services began on Tuesday, 10/17/17. Resident #62 received three (3) days of RNP services that week. -- During the week of 10/22/17-10/28/17, Resident #62 received three (3) days of RNP services. -- During the week of 10/29/17-11/04/17, Resident #62 received three (3) days of RNP services. -- During the week of 11/05/17-11/11/17, Resident #62 received five (5) days of RNP services. -- During the week of 11/12/17-11/18/17, Resident #62 received five (5) days of RNP services. -- During the week of 11/19/17-11/25/17, Resident #62 received six (6) days of RNP services. -- Resident #62 received RNP services on 11/27/17, 11/28/17, and 11/29/17. -- RNP services ended on 11/29/17. During an interview on 04/25/18 at 3:47 PM, the Center Nurse Executive (CNE) agreed Resident #62 did not receive RNP services six (6) times a week as ordered during the following weeks: 10/22/17-10/28/17 10/29/17-11/04/17 11/05/17-11/11/17 11/12/17-11/18/17 The CNE stated Resident #62 received RNP services through 01/03/18 as ordered by the physician. However, she stated she could not locate Restorative Nursing Records for (MONTH) (YEAR) or (MONTH) (YEAR). The CNE stated she could not explain why the Restorative Nursing Records for (MONTH) (YEAR) stated RNP services ended on 11/29/17.",2020-09-01
657,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,690,D,0,1,FJW311,"Based on observation and staff interview, the facility failed to ensure staff provided perineal care (peri care) in a manner to prevent the potential development of urinary tract infections to the extent possible for Resident #99. This was evident for one (1) of one (1) residents reviewed for urinary tract infections. Resident identifier: #99. Facility census: 156. Findings include: a) Resident #99 Observations on 04/24/18 at 11: 39 AM, noted nurse aide (NA) gathering supplies and providing incontinence care for this resident. NA Employee #86 (E#86) placed several clean, folded washcloths directly into the sink basin, shared with two (2) other residents in this room. She ran warm water from the faucet over them until they were completely submerged. E#86 squeezed out the excess water with her gloved hands, then took them to the resident's bed. The resident was incontinent of soft, semi-formed stool which was contained in the perineal and rectal areas and between her legs. E#86 at first cleaned the resident from the front to the back with one of the washcloths as the resident lay on her left side. She disposed of that washcloth into a clear, plastic bag. When E#86 got to the last washcloth, there was still bowel movement in the vulva/perineal area. She folded over the last, used wash cloth repeatedly, and made three (3) more swipes with that soiled wash cloth to remove the last of the bowel movement from the vulva and perineal area. During an interview with the director of nursing (DON) on 04/25/18 at 6:00 p.m., she said it was against the facility's policy to soak washcloths in a sink basin. She said staff were supposed to use the resident's plastic wash basin for that purpose. The DON also agreed that it was not an acceptable practice to reuse a soiled washcloth to clean the perineal area of an incontinent resident. She said she would do staff education to all staff right away. These findings were shared with the administrator on 04/26/18 at approximately 9:30 a.m. No further information was provided by the facility prior to exit. Observations on 04/24/18 at 11: 39 AM, noted nurse aide (NA) gathering supplies and providing incontinence care for this resident. NA Employee #86 (E#86) placed several clean, folded washcloths directly into the sink basin, shared with two (2) other residents in this room. She ran warm water from the faucet over them until they were completely submerged. E#86 squeezed out the excess water with her gloved hands, then took them to the resident's bed. The resident was incontinent of soft, semi-formed stool which was contained in the perineal and rectal areas and between her legs. E#86 at first cleaned the resident from the front to the back with one of the washcloths as the resident lay on her left side. She disposed of that washcloth into a clear, plastic bag. When E#86 got to the last washcloth, there was still bowel movement in the vulva/perineal area. She folded over the last, used wash cloth repeatedly, and made three (3) more swipes with that soiled wash cloth to remove the last of the bowel movement from the vulva and perineal area. During an interview with the director of nursing (DON) on 04/25/18 at 6:00 p.m., she said it was against the facility's policy to soak washcloths in a sink basin. She said staff were supposed to use the resident's plastic wash basin for that purpose. The DON also agreed that it was not an acceptable practice to reuse a soiled washcloth to clean the perineal area of an incontinent resident. She said she would do staff education to all staff right away. These findings were shared with the administrator on 04/26/18 at approximately 9:30 a.m. No further information was provided by the facility prior to exit.",2020-09-01
658,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,726,H,0,1,FJW311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, family interview and record review, the facility failed to ensure nursing staff had the knowledge, skills, and abilities to assure resident safety and 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. A deficient practice was cited at immediate jeopardy for the care area of Freedom from Abuse, Neglect and Exploitation (F 600). A deficient practice was cited at immediate jeopardy for the care area of Infection Control (F 880). Harm was cited in the care areas of Quality of Care (F 684, F 686 and F 688). A deficient practice was also cited at F 677. This practice had the potential to affect more than a limited number of residents. Facility census: 156. a) Resident #119 - Free from Abuse and Neglect The facility failed to provide timely incontinence care to Resident #119. The resident also tearfully reported being verbally abused by a nurse aide because he had called the nurses' station for help after no one responded to his call bell for thirty (30) minutes. The lack of incontinence care and the verbal abuse caused the resident to experience pain, skin breakdown, and psychological harm. Until the surveyor identified the resident's problems and intervened, staff were not aware of the seriousness of his condition. These findings were determined to constitute immediate jeopardy to Resident #119. After consultation with the Office of Health Facility Licensure and Certification (OHFLAC) at 1:25 PM on 04/25/18, and preparation of a written statement, the Administrator and Director of Nursing were notified of the Immediate Jeopardy. The facility provided an acceptable at 4:17 PM on 04/25/18. After verifying implementation of the plan of correction, the immediate jeopardy was abated at 5:26 PM on 04/25/18. No deficient practice remained for this requirement after removal of the immediate jeopardy. This affected one (1) of seven (7) residents reviewed for activities of daily living. During the initial screening for the Long Term Care Survey Process, an interview on 04/23/18 at 11:37 AM, Resident #119 stated he had a pressure ulcer on his buttock from sitting in urine for 30 minutes or longer. He went on to explain he could not walk, that he tried to use a urinal, but sometimes did not get all of the urine in the urinal. Medical record review found his [DIAGNOSES REDACTED].>- muscle weakness - heart failure - Retention of urine - Type 2 Diabetes underlying condition with hyperosmolarity - Chronic [MEDICAL CONDITIONS] - Obesity - History of pressure ulcers on the right heel and penis According to his minimum data set assessment (MDS) with an assessment reference date (ARD) of ____, his Brief Interview for Mental Status Score (BIMS) was 15, indicating he was cognitively intact. Review of his medical records found no mention of current pressure ulcers. Skin Check Performed Sheets dated from 01/27/18 to 04/23/18 documented the following: - 01/27/18- No Skin Injury/Wounds by Licensed Practical Nurse (LPN) #172 - 02/04/18 -No Skin Injury/Wounds by LPN #92 - 02/10/18- No Skin Injury/Wounds by LPN #172 - 02/17/18- No Skin Injury/Wounds by LPN #92 - 02/24/18- No Skin Injury/Wounds by LPN #172 - 03/03/18- No Skin Injury/Wounds by LPN #92 - 03/10/18- No Skin Injury/Wounds by LPN #172 - 03/17/18 -Yes Skin Injury/Wounds identified No New Skin Injury/Wounds Type of Skin Injury/Wounds Moisture Associated Skin Damage by Registered Nurse (RN) #4 - 03/24/18- No Skin Injury/Wounds by LPN #172 - 04/02/18- No Skin Injury/Wounds by RN #4 - 04/07/18- No Skin Injury/Wounds by LPN #33 - 04/23/18 -No Skin Injury/Wounds by LPN #92 On 04/25/18 at 9:15 AM, Wound Care Nurse #120 agreed to do a complete skin assessment with the surveyor present. On entering the room, Resident #119 was emotional and tearful saying that he was, chewed out, by Nurse Aide #96 for calling the nurses' station with his cell phone. He stated that she told him to only use his call light that was what it was for and not to call the nurses' station again. He said NA #96 told him that he was not the only one on this floor and he just needed to wait his turn. He said he responded by telling her he used the call light and had been waiting for more than 30 minutes before he called the nurses' station with his cell phone because his skin was on fire from sitting in urine. Resident #119 told this to the surveyor, Wound Care Nurse #120, and Nurse Aide #84. With the resident's permission, Wound Care Nurse #120 pulled the sheets back revealing a very large red excoriation on his upper outer thighs. Further investigation found areas of broken skin under his scrotum and coccyx. The resident's tee shirt was saturated with urine up his back and had small amount of stool on the bottom. The resident said NA #96 had changed him, therefore the nurse aide left him with a soiled shirt. Wound Care Nurse #120 removed the resident's tee shirt. When the nurse asked how long his skin had been in this condition, the resident replied it had been a year - that it started after being on this floor for a week. The complete skin audit by Wound Care Nurse #120 found: - 1. Pressure Ulcer Stage II on Coccyx - 2. Pressure Ulcer Stage II on right ear - 3. Excoriated areas bilateral groin, under both breast, bilateral abdominal folds, bilateral upper outer thighs and bilateral calf's. - 4. Reddened area to the right great toe, second and third toes, right heel. During an interview on 04/25/18 at 9:35 AM, Wound Care Nurse #120 stated that he was, Just mortified by what was just discovered, referring to the condition of Resident #119's skin. He went on to say he had no excuse and they had failed this resident. On 04/25/18 at 9:45 AM, the DoN was informed of the findings for Resident #119. She said she was already aware and was working on a plan of correction. On 04/25/18 at 1:10 PM, Resident #119 said that he was still upset over the NA #96 fussing at him that morning and it was not the first time he had had to wait for over 30 minutes for assistance. He went on to say he had called his wife many times to have her call the facility to ask them to help him. The resident's care plan, dated 04/03/17 included a plan for impaired skin integrity due to his psoriasis, Moisture Associated Skin Damage (MASD), and history of pressure ulcers. The interventions were: - Monitor skin for signs/symptoms of skin breakdown i.e. - Observe skin condition with ADL care daily and report abnormalities - Skin check per policy - Weekly skin assessment by license nurse - Weekly wound assessment The facility's policy, NSG236 Skin Integrity Management Effective date 07/01/01, Revision date 11/28/16, directed the staff to continually observe and monitor for skin changes and implement revisions to the plan of care. The purpose, to provide safe and effective care to prevent the occurrence of pressure ulcers and promote healing of all wounds The facility's policy,OPS300 Abuse Prohibition, effective date 06/01/96 Revision date 04/07/17, stated all employees would be trained ongoing to prevent abuse. The facility reported the resident's allegations concerning NA #96 to the Nurse Aide Program at OHFLAC on 04/26/18. These findings were determined to constitute immediate jeopardy to Resident #119. After consultation with the Office of Health Facility Licensure and Certification (OHFLAC) at 1:25 PM on 04/25/18, and preparation of a written statement, the Administrator and Director of Nursing were notified of the Immediate Jeopardy. The facility provided an acceptable at 4:17 PM on 04/25/18. After verifying implementation of the plan of correction, the immediate jeopardy was abated at 5:26 PM on 04/25/18. No deficient practice remained for this requirement after removal of the immediate jeopardy. The Facility's Plan of Correction: On 04/25/18 The RN wound nurse evaluated Resident #119's skin at 3:50 PM, a pain assessment was conducted by RN wound nurse at 3:50 and a Social Worker (SW)/designee will interview the resident on 04/25/18 by 5 PM, to address alleged psychological harm with corrective action upon discovery. The physician was notified of changes at 3:50 PM, by RN wound nurse. On 04/25/18 the center SW reported the allegation of neglect to the appropriate state agencies at 10:44 AM. All residents of the facility have the potential to be affected. The DON/designees will begin to conduct observation of all residents' skin on 04/25/18 with corrective action upon discovery. SW/designees will begin to interview all interview able residents on 04/25/18 to ensure that incontinence care and pain are addressed timely and that residents have not experienced any psychologic harm as evidenced by lack of verbalized fear and be completed by 04/25/18 with corrective action upon discovery. The DON/designees will begin observations of non-interview able residents' skin sweeps on 04/04/25/18 and completed by 04/26/18, including completion of the non-interview able pain evaluation with corrective action upon discovery. The Nurse Practice Educator (NPE)/designee will re-educate all licensed staff on accurate completion and documentation of the weekly skin checks to monitor the patients and his/her wound's response to treatments and interventions beginning on 04/25/18 and all center staff will be re-educated to ensure all center residents are free from neglect, including pain and psychological harm, respond to residents in a timely manner with a post-test to validate understanding beginning 04/25/18. Staff not available during this timeframe will be provided re-education including post-test by the NPE/designee, upon return to work. New hires will be provided education and post-tests during orientation by the NPE/designee. The Unit Managers (UMS)/designee will conduct observation of weekly skin checks, timely response of continence care, pain monitor flow sheets daily for two weeks across all shifts including weekends, then three times a week for two weeks then randomly thereafter to ensure that weekly skin checks are accurate, incontinence care is provided in a timely manner to avoid skin breakdown, and residents pain is addressed based on daily MAR pain evaluation. The SW/designee will conduct sixteen (16) random interviews daily for two weeks across all shifts including weekends, then three times a week for two weeks then randomly thereafter to ensure that residents do not experience any neglect or psychological harm. Trends identified will be reported by the DON monthly to the Quality Improvement Committee (QIC) for any additional follow up and/or in-servicing until the issue is resolved and randomly thereafter as determined by the QIC. b) Activities of Daily Living Provided to Dependent Residents The failure to ensure dependent residents received needed care and services resulted in actual harm for Resident #26. Resident #26 did not receive care needed care for her hands, resulting in a Stage II pressure area on her palm and pain when attempts were made to open her hand. The facility's failure to ensure Resident #119 received needed skin care and prompt incontinence care were determined to result in actual harm to this resident as he developed pressure ulcers and painful excoriation. Resident #80 needed hygienic measures for hand contractures. Resident identifiers: #80, #26, and #119. Facility census: 156. 1) Resident #26 Observation of the resident at 4:45 p.m. on 04/23/18, found the resident's left and right hands appeared contracted. The resident had no splinting devices in use. Review of the resident's current care plan found the following focus/problem: - Resident requires assistance with ADL's (activities of daily living) due to limited mobility. The goal associated with the problem: - Residents/Patients ADL care needs will be anticipated and met throughout the next review period. Interventions included: - Monitor for decline in ADL function. Refer to rehabilitation therapy and decline in ADL's is noted. Provide resident extensive assist for bed mobility, dressing, eating, personal hygiene, and grooming. While investigating to determine why the resident had possible contractures without splinting devices the following observations were made: - Observation of the resident at 1:44 p.m. on 04/25/18, with OT #171 revealed, OT #171 was able to open the resident's right hand with without difficulty. When opened, a sour odor, coming from the resident's right hand was evident. OT #171 said she had sinuses and could not smell the odor. When OT #171 attempted to open the resident's left hand, a strong putrid, foul smelling, sour odor, emanated from the hand. OT #171 acknowledged she could smell the odor coming from the left hand. OT #171 said she would get staff to clean the resident's hands. OT #171 was unable to fully extend all the fingers of the resident's left hand. The ring finger was pressed into the palm of the resident's hand. It was evident the finger nailwas cutting into the palm of the resident's hand. OT #171 said, She was never like this when we finished with therapy services in January. When OT #171, discarded her gloves in the trash can in the corner of the resident's room, the foul odor from the gloves could be smelled coming out of the trash can. Throughout the observation, the resident said, Ouch, that hurts, that hurts, when OT #171 was attempting to work with the resident's left hand. The resident also said, I need my fingernails cut, the doctor said so. The resident nails were long jagged and unclean. These observations were discussed with the director of nursing (DON) at 2:00 p.m. on 04/25/18. The DON said she would have a nurse soak the resident's hand in warm water, assess the condition of the hands and cut the fingernails. At 2:15 p.m. on 04/25/18, Licensed Practical Nurse (LPN) #26 was observed cleaning the resident's hands and cutting the fingernails. LPN #26 acknowledged the resident had a foul smelling odor coming from both hands. LPN #26 said she thought she could see a, break in the skin, on the palm of the left hand. She said, I won't know for sure until I soak the hand and get it to open a little more. At 3:15 p.m. on 04/25/18, the director of rehabilitation services, Employee #170 said the resident was screened for services on 04/19/18. [NAME] #170 said, When we screen a resident we can't touch them. If the patient can't tell us what is wrong or the staff don't tell us we don't know. She said the resident didn't want any therapy but did agree to a speech evaluation. E#170 said staff would not have looked at the resident's hands. At 3:17 p.m. on 4/25/18, the information received from E#170 was discussed with the DON. The DON said she was unaware a therapist could not touch a resident during a screen. At 8:10 a.m. on 04/26/18, observation with the DON found the DON confirmed the resident had a Stage II pressure area on the left hand, just under the ring finger on the palm of left hand. The DON acknowledged the resident still had a slight sour odor coming from the left hand. At 8:35 a.m. on 004/26/18, the DON said, I am taking care of this, calling the doctor, the residents family and will get an order for [REDACTED]. The DON acknowledged staff had not been cleaning the resident's hands as needed to prevent the odor. The DON said the skin check, completed by the nursing staff on 04/20/18, should have caught the problem. The DON was unable to provide any information to support the facility was aware of the foul odor of the resident's hands, the left hand contracture, or the development of a Stage II pressure area on the palm of the resident's left hand, prior to surveyor intervention. The failure to provide extensive assistance for personal hygiene, (ADL care and cleaning) of the residents hands lead to the foul odor coming from both the left and right hands. Had ADL care been provided, the facility may have recognized the inability of the resident to voluntarily open both the left and right hands. Had the facility addressed this decline, the contracture of the left hand may have been prevented. The failure to address the resident's contracture of the left hand lead contributed to the development of a Stage II pressure ulcer to the left hand. This was determined to constitute actual harm to this resident. 2) Resident #119 During the screening for the initial pool of the Long-Term Care Survey Process, an interview on 04/23/18 at 11:37 AM with Resident #119 revealed he had a pressure ulcer on his lower buttock from sitting in urine for 30 minutes or longer. He went on to explain he could not walk, and tried to use a urinal, but sometimes did not get all the urine in the urinal. He stated there was not enough staff last night - one aide was with two (2) nurse aides in training. According to the resident, it takes more than an hour for staff to answer a call light. He said he had been told his aide was on break, and the aides also told him they were short staffed. This was mostly on the 3:00 PM to 11:00 PM or the 11:00 PM to 7:00 AM shifts. On 04/25/18 at 9:15 AM, Resident #119 was emotional and tearful saying that he was chewed out by the Nurse Aide #96 for calling the nurses' station with his cell phone. He stated she told him to only use his call light, that was what it was for, and not to call the nurses' station again. He said, NA #96 told him that he was not the only one on this floor and he just needed to wait his turn. He said he responded by telling her he used the call light and had been waiting for more than 30 minutes before he called the nurses' station with his cell phone, because his skin was on fire from sitting in urine. The resident told this to the surveyor, Wound Care Nurse #120, and Nurse Aide #84. On 04/25/18 at 9:15 AM, Wound Care Nurse #120 agreed to do a complete skin assessment with the surveyor present. A complete skin audit by Wound Care Nurse #120 found: - 1. Pressure Ulcer Stage II on Coccyx - 2. Pressure Ulcer Stage II on right ear - 3. Excoriated areas bilateral groin, under both breast, bilateral abdominal folds, bilateral upper outer thighs and bilateral calf's. - 4. Reddened area to the right great toe, second and third toes, right heel. The failure of the facility to ensure needed skin care and prompt incontinence care were determined to result in actual harm to this resident. During an interview on 04/25/18 at 9:45 AM, when informed of findings, the DoN stated she had heard from Wound Care Nurse #120 and was addressing the problem. On 04/25/18 at 1:10 PM, Resident #119 said that he was still upset over the NA #96 fussing at him that morning and it was not the first time he has had to wait for over 30 minutes for assistance. He went on to say he has called his wife many times to have her call the facility to ask them to help him. 3) Resident #80 Observation on 04/23/18 at 3:40 p.m. found this resident lying in bed. He had contractures of both hands. There were no splints, palm guards, or any type of device in place to either hand. Observations on 04/24/18 at 10:30 a.m., again found he had no splints, palm guards, rolled washcloths or any devices in either hand. He held both hands firmly closed. At 12:15 p.m. on 04/24/18, while accompanied by Registered Nurse Employee #13 (E#13), a white washcloth was found placed partially in his left hand, and a thin, smaller, yellow-colored cloth was was found placed partially in his right hand. When asked whether these cloths were placed in his hands later than 10:45 a.m. that morning, E#13 replied in the affirmative and said she had placed them. On 04/24/18 at 12:15 p.m., E#13 removed the cloths in preparation for inspection of the palms of both hands. When the nurse removed the cloths from his hands, a foul smell was immediately noted. When asked if that foul odor came from the cloths having been placed in his hands, E#13 stated I can't put my nose on them to smell them. E#13 tried to move the contracted fingers so the palms could be visualized. His fingers were drawn down tightly, which made visualization of the palms inadequate. She moved the right thumb about one-quarter of an inch outward, which then allowed visualization of a dry, reddened area on the skin of the fourth finger of the right hand. The thumbnail of the right hand lay directly on top of, and pressing against, the reddened area of the fourth finger beneath it. The right thumbnail was smooth, but long, protruding beyond the flesh at the tip of the thumb a quarter of an inch. It needed trimmed. At 3:15 p.m. on 04/24/18, Occupational Therapist Employee #171 and wound nurse/registered nurse E#120 came to the resident's bed. A white wash cloth and a thinner, yellow cloth lay on his chest. The palms could only slightly be visualized. E#120 said they were aware of the reddened area to the right fourth finger and were monitoring and treating it. He said the right thumbnail needed trimmed. Review of a grievance on 04/24/18 at 4:00 p.m. found one from the daughter of Resident #80 dated 02/19/18. It stated Daughter concerned resident's hands are not being cleaned and nails aren't being clipped as often as they should be. The corrective action from Unit 3 Nursing Staff stated Ordered hands to be cleaned daily and nails trimmed every Tuesday and Friday. Review of the (MONTH) Medication Administration Record [REDACTED]. This was a one (1) week audit. The (MONTH) MAR indicated [REDACTED]. Staff initialed its completion on 03/06/18 and 03/09/18. The space for 03/13/18 was left blank. This, too, was on the MAR for one (1) week. Review of the resident's care plan on 04/24/18 at 4:00 p.m., found an area of focus for the resident being dependent for ADL care as evidenced by multiple contractures. A goal included that he would be clean, dry and odor free through next review. The care plan was not fully developed to include cleaning his hands daily and/or how to accomplish that task, or anything about nail trimming. Observation on 04/25/18 at 2:25 p.m., accompanied by licensed nurse Employee #80 (E#80) found no cloths, palm guards or any devices in either hand. When asked why there was no padding or cloth between the thumbnail and the fourth finger of the right hand to reduce pressure, she threaded the yellow cloth into the resident's right hand. She ensured it padded the skin between the right thumbnail and the reddened area to the fourth finger beneath it. The nurse agreed the right thumbnail was too long. She said she had some clippers and would cut and trim that offending right thumbnail. The nurse also placed a washcloth in the palm of the left hand. During an interview on 04/25/18 at 6:00 p.m. , the director of nursing said there should not have been an odor from the palms of his hands as it was possible for staff to clean his hands. She was informed that the nurse on 04/24/18 at 3:15 p.m. stated his right thumbnail was too long, and that they were monitoring and treating the reddened skin area to the right fourth finger upon which the right thumb and thumbnail rested. She was also informed that the following day on 04/25/18 at 2:25 p.m. the right thumbnail was still long and in need of trimming. The nurse on duty at 2:25 p.m. on 04/25/18 said she had clippers and would trim the thumb nail right away. A copy of the grievance form dated 02/19/18 conveyed the resident's daughter's concern that his hands were not cleaned and his nails not clipped as often as they should be. The DON acknowledged the grievance. No further information was provided prior to exit. On 04/26/18 at approximately 9:30 a.m., these findings were discussed with the administrator. No further information was provided by the facility prior to exit. c) Quality of Care 1) Resident #147 Resident #147 did not receive insulin as directed by the physician which lead to harm due to critically elevated blood glucose levels, high sodium levels, and acute kidney injury. Additionally, there was no evidence of an assessment of the resident's mental and physical status when his blood sugars were over 600. Furthermore, the resident's antibiotic was stopped prior to completion of the course ordered by the physician, but there was no evidence the physician had ordered it discontinued. Resident identifier: #147. Facility census: 156. An interview with the resident and his daughter at 11:19 a.m. on 04/23/18, found the daughter was very worried about the medical condition of her father. The daughter said her father had been very confused, his blood sugars were high, he had an incontinent episode, and he had a cough. She said her father was recently diagnosed with [REDACTED]. She was fearful he would die if something was not done. She said she talked to someone of Saturday, a nurse she thought, who said she would have to wait until Monday to see the doctor. She said the facility did get a chest x-ray, but she did not think this would tell them if he was having other problems. She believed her father needed to have some blood work and hoping that was going to happen that day. Record review found a [AGE] year-old male resident admitted to the facility on [DATE]. His hospital discharge summary noted the resident was hosptalized on [DATE]. He was treated for [REDACTED]. ANCA (associated small-vessel vasculitis) are autoantibodies produced by a person's immune system that mistakenly attack proteins within the person's [DIAGNOSES REDACTED]s (white blood cell types). The most common subsets of ANCA are those that target the proteins myeloperoxidase (MPO) and proteinase.) The resident was discharged from the hospital to the nursing home on 03/28/18. Review of the resident's medical record found he was seen by the family nurse practitioner (FNP) on Saturday, 04/20/18 for a change in condition. The FNP noted, Chief Complaint / Nature of Presenting Problem: [DIAGNOSES REDACTED], family concerned regarding cough History of Present Illness: The patient is a [AGE] year old male with known history of [MEDICAL CONDITION] and confusion. Patient reports feeling well. Does seem more lethargic today. Daughter reports patient has been coughing and she is worried he has pneumonia as 'this is how it starts, when he looks, lost,' nurse at bedside check patient's blood glucose for noon and BG (blood glucose) was 50. Patient did eat breakfast this morning staff relates. The plan for treatment was: 1. [MEDICATION NAME] decreased to 5 units TID (3 times a day) with meals 2. [MEDICATION NAME] decreased to 20 units QHS (every hour of sleep/bedtime) 3. patient was given lunch, and order to recheck blood glucose one hour after lunch, to notify provider if remains low after a meal orders discussed with nursing A handwritten physician's orders [REDACTED]. Check BMG (a small protein and is readily reabsorbed by kidneys with normal function) 1 hour after lunch due to [DIAGNOSES REDACTED] decrease [MEDICATION NAME] to 20 units QHS decrease insulin [MEDICATION NAME] to 5 units TID (3 times a day) with meals for [DIAGNOSES REDACTED]. Review of the resident's Medication Administration Record [REDACTED] -- The [MEDICATION NAME] was not decreased to 20 units as directed by the physician on 04/20/18. -- The [MEDICATION NAME] was discontinued and was not given at all, until Monday 04/23/18. The resident's blood glucose readings were: - On 04/21/18: BG (Blood Glucose) was 312 at 7:30 a.m. BG 171 at 11:30 a.m. BG 357 at 4:30 p.m. - On 04/22/18: BG 384 at 7:30 a.m. BG 396 at 11:30 a.m. BG 253 at 4:30 p.m. On 04/23/18 at 6:30 a.m., the resident's blood glucose was so high, the facility was unable to obtain a reading. The nurse's note, dated 04/23/18 at 6:37, noted the resident's blood glucose level was over 600. The resident's physician was contacted and ordered, Humalog 10 units now. Recheck glucose in 1 hours. If glucose is higher than 400 repeat 1 dose. At 7:30 a.m. on 04/23/18, the MAR indicated [REDACTED]. Another 10 units of Humalog was administered. At 8:30 a.m. on 04/23/18, the resident's blood glucose was still 511. At 9:40 a.m. on 04/23/18 another 15 units of Humalog was administered, according to the MAR. Nursing staff contacted the physician for this order. A nursing note written at 12:06 a.m. on 04/23/18, noted the physician was contacted and another 20 units of [MEDICATION NAME] was given and the physician said to give the [MEDICATION NAME] that is due tonight. The MAR indicated [REDACTED] There were no nursing notes describing the resident's condition when his blood glucose was above 600; such as was the resident level of consciousness affected, was he thirsty, tired, was his coordination affected, etc. The resident was seen by the physician on 04/23/18 at 7:35 p.m. The plan ordered by the physician: Stat (immediately) labs came back. WBC (white blood cell count) is normal. But BUN/CR (blood urea nitrogen/creatinine ratio) significantly increased from prior. K (potassium) is 5.7. Patient in AKI (acute kidney injury), ordered IVF (intravenous fluids), hold [MEDICATION NAME] and [MEDICATION NAME], give [MEDICATION NAME] for [MEDICAL CONDITION] (high potassium). Recheck BMP (basic metabolic panel) in morning, the low sodium on BMP is due to high BG of over 700. The BG has been checked since then and it is down to 200's no longer in 700's. At 8:40 a.m. on 04/25/18, the director of nursing (DON) was interviewed regarding Resident #126. Before the interview began, the DON said, I already know a medication error was made regarding the physician's orders [REDACTED]. The DON verified the [MEDICATION NAME] was to be decreased to 20 units due to the resident's low blood glucose level of 50 obtained on 04/20/18. She said the new order was transcribed to the MAR, but was then discontinued. The resident never received any [MEDICATION NAME] and the resident's blood glucose levels were above 600, 3 days after the medication was stopped when it should have been reduced. The DON verified the blood glucose level was not obtained after the [MEDICATION NAME] was administered at 11:00 a.m. on 04/24/18. The DON said she had already disciplined the staff involved in the medication errors. The DON confirmed the medication error resulted in treatments that could have been prevented if staff had followed the physician's orders [REDACTED]. The failure to administer insulin as ordered by the physician and to monitor the resident's blood glucose when indicated resulted in actual harm to this resident. On 04/02/18 the physician ordered [MEDICATION NAME] 1 gram IM (intramuscular) daily for the next 4 days, pending the results of the urinalysis. Review of the resident's Medication Administration Record [REDACTED]. There was no explanation why the medication was discontinued, and no evidence the physician was contacted and approved the discontinuation. At 9:21 a.m. on 04/25/18, the DON said the results of the urinalysis showed the resident did not have a urinary tract infection. She said the nursing staff should have documented the physician was contacted and the staff should have obtained an order to discontinue the [MEDICATION NAME]. d) Pressure Ulcers Resident #119, a depende (TRUNCATED)",2020-09-01
659,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,758,D,0,1,FJW311,"**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 six (6) residents reviewed for unnecessary medications was free from antipsychotic medications. The facility administered [MEDICATION NAME] (an antipsychotic medication) intramuscular (IM), without a physician's orders [REDACTED]. In addition, the physician ordered [MEDICATION NAME] to be administered intravenously (IV) when there was no evidence the resident exhibited any behaviors. Resident identifier: #109. Facility census: 156. Findings include: a) Resident #109 Medical record review found the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medication administration records (MARs) for the period from 11/01/17 to 04/24/18, found the resident was ordered a [MEDICATION NAME] IM (intramuscular) injection on the 28th day of every month. Several dosage changes to the [MEDICATION NAME] had been made by the resident's physician since 11/28/17. On 01/17/18, a new physician's orders [REDACTED]. In addition, the physician ordered [MEDICATION NAME] 50 milligrams IM when not aggressive-today or tomorrow. Review of the nursing notes found the Family Nurse Practitioner (FNP) increased the dosage of [MEDICATION NAME] on 01/17/18 because, (Typed as written), Resident aggressive behaviors towards the nurse that started today. The nurse reports the CNA (certified nursing assistant) asked her to help position him. She was unaware the resident had told the CNA he wanted to be left alone. The nurse said she started to help him and he grabbed her hand and bent if backwards and then punched her in the stomach. Resident in the room and shouting expletives towards the other nurse and this provider. He asked this provider to leave or he stated he would hit me. There was no evidence to indicate the staff attempted any non-pharmacological interventions or just simply left the resident alone as he requested on 01/17/18. Also, the FNP noted the staff member was a new nurse most likely unfamiliar with the resident and his behaviors. The FNP even documented the resident had asked the CNA to leave him alone and the new nurse was not advised of this request before she attempted to provide care. The resident had no recorded behaviors on 01/18/18 when the extra dose of [MEDICATION NAME] 50 milligrams was administered. Review of the Medication Administration Record [REDACTED]. [MEDICATION NAME] 350 milligrams was also administered on 01/28/18. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED] [MEDICATION NAME] Solution 100 milligrams. Inject 350 milligrams one time a day starting on the 28th and ending on the 28th every month. The injection was not provided on 02/28/18 as directed by the physician's orders [REDACTED].>There was no explanation provided on the (MONTH) (YEAR), MAR indicated [REDACTED]. Review of the (MONTH) (YEAR), MAR found an order for [REDACTED].>[MEDICATION NAME] Solution 100 milligrams ([MEDICATION NAME]). Inject 350 milligrams intramuscular one time a day starting on the 28th and ending on the 28th, every month due to [MEDICAL CONDITION]. Further review of the (MONTH) (YEAR), MAR found, [MEDICATION NAME] 350 milligrams, intramuscular was given on 03/02/18 and 03/28/18. The orders directed the [MEDICATION NAME] IV be given on 03/28/18. Review of the physician's orders [REDACTED]. The nursing notes did not reference why the [MEDICATION NAME] was administered on 03/02/18. There was no evidence the resident had any behaviors on 03/02/18. Review of the behavior monitoring logs for (MONTH) (YEAR) found the resident was being monitored for rejection of care. The resident had no behaviors recorded for the entire month of (MONTH) (YEAR). The (MONTH) (YEAR) behavior monitoring log failed to list the behaviors for which the resident was being monitored. The log indicated the resident had no behaviors during the entire month of (MONTH) (YEAR). The behavior monitoring log for (MONTH) (YEAR) had no behaviors listed for staff to monitor and the log indicated the resident had no behaviors for the entire month. At 2:41 p.m. on 04/24/18, the Director of Nursing reviewed the resident's medical record. She confirmed she was unable to find a physician's orders [REDACTED]. Solution, 100 milligrams ([MEDICATION NAME]). Inject 350 milligrams intramuscular, on 03/02/18. The DON also reviewed the January, February, and (MONTH) (YEAR) behavior monitoring logs and confirmed staff should have documented any behavior exhibited by the resident on the behavior monitoring logs and the logs should have contained the behaviors for which the staff were monitoring. The DON was asked why 50 milligrams of [MEDICATION NAME] was ordered on [DATE] when the resident was having no behaviors. She replied, That's a good question, I don't know and the FNP who wrote that order doesn't work here anymore. The DON suspected the [MEDICATION NAME] was administered on 03/02/18 because the staff missed the dose that should have been administered on 02/28/18 but she could not verify that assumption because there was no documentation present in the chart.",2020-09-01
660,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,761,E,0,1,FJW311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed, in collaboration with the pharmacist, to ensure the safe and effective use of medications. Five (5) opened and partially used bottles of eye drops had no date to identify when the medication was initially opened. Four (4) insulin pens were opened and partially used with no date to indicate the initial opened date. Three (3) vials of insulin were opened and partially used with no date to indicate the initial date used. One (1) medication did not have a pharmacy label on it to indicate to whom it belongs. This was found on one (1) of two (2) medication carts on the third floor. This had the potential to negatively impact the safety and/or potency of the medications. In the third-floor medication storage room there was whisky and moonshine in the cabinet without a name to indicate to whom it belonged to any method to account for the amount dispensed. This had the potential to affect more than a limited number of residents. Residents identifiers: #100, #126, #76, #86, #112, #108, #2, #119, #67 and three (3) unknown due to no name on the medication. Facility census: 156. Findings included: a) Observation on [DATE] at 9:38 AM, found one (1) of two (2) medication carts on the third floor had nine (9) opened and partially used bottles eye drops, five (5) with no dates to indicate the initial date it was opened for the following: - Resident #100 - artificial tears - Resident #126 - [MEDICATION NAME], Bausch and Lomb - Resident #76 - artificial tears - Resident #86 - artificial tears - Liquitears - no name or open date, but opened and partially used. Four (4) of five (5) insulin pens observed were opened and partially used without a date to indicate the initial opened date for the following: - Resident #112 - [MEDICATION NAME] - Resident #108 - [MEDICATION NAME] - Resident #2 - [MEDICATION NAME] flextouch - Resident #119 - [MEDICATION NAME] Pen Three (3) of three (3) vials of insulin were opened and partially used with no date to indicate the initial dates it was opened and used for the following: - Resident #108 - [MEDICATION NAME] - Resident #2 - [MEDICATION NAME] - Resident #67 - [MEDICATION NAME] A Trulicity (used to treat diabetes) pen had no pharmacy label on the medication to identify the resident to whom it belonged or directions for administrating. A bottle of oyster shell calcium had an expiration date of ,[DATE] (March (YEAR)). In an interview on [DATE] at 9:50 PM, Licensed Practical Nurse #92 agreed all of the identified medications should have had an opened date on them. She could not tell who the Trulicity belonged to or why it was in the medication cart without a name. She said she was on vacation and was unaware this medication cart had all these problems and she would make sure all medications are replaced and labeled. On [DATE] at 9:55 AM, observations of the third-floor medication storage room found a bottle of Red Label Whisky 375 ounces, with about ,[DATE] of the whiskey missing and a bottle of Sugarland Moonshine 1.7 ounces not opened. These did not have a name to identify ownership or any method to account for the amount dispensed. During an interview on [DATE] at 10:00 AM, Unit Manager #13, the third-floor manager, stated she did not know who the alcohol belonged to and did not think she needed to have a sheet to show when or how much was dispensed. On [DATE] at 10:29 AM, when informed of findings, the director of nursing agreed there should be dates on all the identified medications, the expired on e should have been thrown out, and the whisky should have had an account sheet.",2020-09-01
661,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,803,E,0,1,FJW311,"Based on observation, resident interview, and staff interview, the facility failed to ensure menus were followed and residents received the correct portion size as indicated by the menus. This had the potential to affect more than a limited number of residents. Facility census: 156. Findings include: a) Resident interviews Several anonymous interviews with residents on 04/23/18, revealed residents did not think the portion sizes were large enough on some food items served at meals. b) Observation of the evening meal on 04/25/18 At 5:45 p.m. on 04/25/18, upon entering the facility's kitchen, the evening meal service was already in progress. Two (2) metal serving carts containing meals had already been filled and were being transported to the second floor. Observation of the food serving line found some residents were being served beef stew, apple salad, and a biscuit for the evening meal. The portion size of the beef stew appeared small. The dietary manager (DM) was asked if staff were using the correct serving scoop for the beef stew. The DM looked at the scoop and said the kitchen employee was using a 3 ounce scoop instead of a 6 ounce scoop. He said he would get the proper scoop to serve the beef stew. The DM confirmed residents would only be receiving one-half (1/2) of the recommended serving of beef stew. The DM instructed the kitchen employee to use the #6 scoop for the beef stew. The DM did not comment on how the facility would correct the meals already served to the residents. At 5:43 p.m. on 04/25/18, the administrator was advised of the observation and the DM's response. The administrator had no further information to provide and made no further comments.",2020-09-01
662,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,804,E,0,1,FJW311,"Based on observation, individual resident interviews, interviews during the resident council meeting, and staff interview, the facility failed to ensure food was served at the proper temperatures. In addition, the food served at the evening meal on 04/25/18 was not attractive and appetizing. The facility allowed liquids from food items to run together on the resident's plates. A biscuit was also on the plate and was soaking up the gravy from the beef stew and the white liquid from the apple salad. This practice had the potential to affect more than a limited number of residents receiving meals from the facility. Facility census: 156. Findings include: a) Resident interviews Eight (8) anonymous residents, interviewed on 04/23/18, complained of cold food at meal times. b) Resident council meeting Several anonymous residents who attended the council meeting at 10:00 a.m. on 04/25/18, complained of receiving cold foods. The residents said they had talked to the administrator about the cold food and the poor taste of some food items. Residents said the facility did employ a new dietary manager and some improvement had been made, but more improvements were needed. c) Temperatures of food on the TCU (transitional care unit) Temperatures of the last tray served on the first cart on the TCU unit were obtained with the dietary manager at 1:09 p.m. on 04/23/18. The temperatures were: -- Mashed potatoes: 116 degrees Fahrenheit (F) -- Sausage with peppers and onions sub: 99 degrees F -- Vegetable Soup: 99 degrees F -- Sweet Potato Fries: 87 degrees F The DM said he would expect hot food items to be at least 135 degrees at the time of service. At approximately 2:30 p.m. on 04/23/18, the DM manager provided the temperatures taken at the time of food service in the facility's kitchen: Sausage with pepper and onion Sub.: 162 degrees Sweet potato wedges: 168 degrees Puree sweet potato wedges: 160 degrees Vegetable soup: 190 degrees Pureed vegetable soup: 182 degrees d) Observation of the evening meal on 04/25/18 At 5:45 p.m. on 04/25/18, the evening meal service was already in progress. Two (2) metal serving carts containing meals had already been filled and were being transported to the second floor for the evening meal. Observation of the food serving line, found some residents were being served beef stew, apple salad, and a biscuit for the evening meal. The beef stew in a rich brown gravy, the apple salad, and a biscuit were served together on a dinner plate. The mayonnaise and sour cream dressing from the apple salad and the brown gravy from the beef stew were running together on the dinner plate. The biscuit was soaking up the liquid from the beef stew and from the apple salad. At 5:50 p.m. on 04/25/18, when asked about the appearance of the plate of food, the dietary manager asked the kitchen staff to get bowls either for the apples or for the beef stew. The DM made no comment about the serving the residents' biscuits separately. At 5:43 p.m. on 04/25/18, these observations, temperatures, and resident interviews were discussed with the administrator. At the close of the survey on 04/26/18 at 4:30 p.m., no further information had been provided.",2020-09-01
663,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,812,E,0,1,FJW311,"Based on observation and staff interview, the facility failed to ensure food preparation equipment was clean. The facility could not ensure the ice cream cooler was keeping food at a safe temperature as the thermometer in the ice cream cooler was broken. The floor just inside the facility's walk-in refrigerator was covered with large chunks of ice from condensation dripping from the seal around the door. These practices had the potential to affect all residents receiving nourishment from the kitchen. Facility census: 156. Findings include: a) Observation of the kitchen A tour of the kitchen with Employee #63, the executive chef (dietary manager), at 10:00 a.m. on 04/23/18 found the following soiled equipment: - Reach-in upright refrigerator #3 had food debris on the shelves and the floor of the refrigerator. A greasy substance, that could be wiped with a finger was on the floor of the refrigerator. The glass door was dirty. - The ice cream chest had a light brown liquid splashed all down the front of the chest. The thermometer inside the chest was broken. The DM verified he was unsure of the temperature inside the chest. - A three (3) shelf pink serving cart had food debris on all three (3) shelves. Lint and other substances were on the wheels of the cart. - The door of refrigerator #2 was stained with a brown liquid substance. The same substance was also running down the wall to the right of the refrigerator. - The stainless steel cabinet holding the coffeemaker, had debris on the inside shelves as well as the two (2) outside doors. - A stainless steel three (3) shelf serving cart had black electrical tape on the handles. The cart was dirty with food debris. Lint and food debris were on the wheels of the cart. - Two (2) white, wheeled three (3) shelf serving carts were stained with a brown substance on the top shelf and a pink substance on the bottom shelf. The bottom shelves contained dried food debris. - The walk-in freezer had beads of water dripping around the inside seal of the door. (Water droplets fell on the surveyor's head when stepping inside the door.) Several big ice chunks, the size of a dessert plate, approximately 2 to 3 inches thick, were found just inside the door on the floor of the freezer. Several sealed plastic bags, with sliced pepperoni and ham, located just inside the door were cover with a heavy frost that could be scraped off with a fingernail. The dietary manager confirmed these findings. At 5:55 p.m. on 04/25/18, the administrator observed the condition of the walk-in freezer. The observations of the kitchen equipment found on 04/23/18, were also discussed with the administrator.",2020-09-01
664,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,880,K,0,1,FJW311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, observation and infection control policy review, the facility failed to maintain an effective infection control program to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. The facility failed to effectively implement isolation practices for Resident #149. Resident #149, who was diagnosed with [REDACTED].#108) who did not [MEDICAL CONDITION] or [MEDICAL CONDITION] [DIAGNOSES REDACTED].#149 would pick scabs from her open [MEDICAL CONDITION] and flick them about. Resident #108 was unable to understand the need for, and to independently practice hygienic measures such as handwashing. Resident #108 ambulated about the room, touching various environmental objects, and about on the nursing unit at will. This had the potential for Resident #108 to become a vector for Resident #149's infectious disease processes, carrying infective material where other residents, staff, and visitors might have contact. These findings were determined to pose an immediate jeopardy to the health and well-being of others. After consultation with the Office of Health Facility Licensure and Certification (OHFLAC) on 04/25/18 at 12:48 PM and preparation of a written statement regarding the identified deficient practice, the Administrator and Director of Nursing (DoN) were notified of this immediate jeopardy on 04/25/18 at 1:28 PM. The facility provided an acceptable Plan of Correction at 3:45 pm on 04/25/18. After determining the facility had implemented its plan of correction, the immediate jeopardy was abated on 04/25/18 at 3:53 pm After removal of the immediate jeopardy, a deficient practice, with the potential to affect more than a limited number of residents, remained at a scope and severity of E. A nurse administered medications to Resident #44 after dropping them on the medication cart, picking them up with her bare hands, and placing them in a medication cup with other medications. For Resident #99, observations of incontinence care identified breaches of technique that increased the potential for urinary tract infection. Resident Identifiers: #149, #108, #44, and #99. Facility census: 156. Findings included: a) Resident #149 An observation on 04/23/18 at 10:59 AM, noted a sign on a resident's door, See nurse before entering room. Licensed Practical Nurse (LPN) #92 said the resident was in contact isolation because she had [MEDICAL CONDITION] in her nose in the hospital and all the opened sores on her body. She also identified the resident was [MEDICAL CONDITION] positive. It was also noted there was another resident in the room. LPN #92 said that her roommate did not [MEDICAL CONDITION] or [MEDICAL CONDITION]. On 04/23/18 at 11:00 AM, observations found Resident #149 sleeping with her head resting on the side rail. She had multiple opened and scabbed over areas on all exposed skin, some were actively bleeding. Observation on 04/23/18 at 2:28 PM, found Resident #149 awake, sitting on her bed picking at a scabbed area on the top of her head. The curtain between the beds was half open and her roommate was up looking for her TV remote on Resident #149's bedside table. An observation on 04/23/18 at 3:33 PM, the curtain between the beds was pulled less than half way between the beds. During an interview on 04/23/18 at 3:43 PM, the director of nursing (DoN) said the resident (#149) had [MEDICAL CONDITIONS]. The doctor wanted her to be in contact isolation because she picked at her sores. She added that her roommate did not have a history [MEDICAL CONDITION] or [MEDICAL CONDITION], but did not need to be moved. During an interview on 04/25/18 at 9:06 AM, Infection Control Nurse (ICN) #167 said the attending physician said Resident #149 needed to be in contact isolation and a private room. It was brought it the attention of the Administrator, DoN, and the Admission director. They were in on the conversation about moving one of the residents. She said that they try to keep the curtain pulled, because she knows Resident #149 is always picking at her wounds and flicking bits of the scabs about. When informed that the curtain was not always pulled, because the resident's (in isolation) feet and bottom of the bed could be seen. ICN #167 stated that Resident #108 (Resident #149's roommate) kept pulling the curtain back. During an interview on 04/25/18 at 1:29 PM, the DoN said she was not told the doctor had ordered Resident #149 moved to a private room. Resident #149 was admitted on [DATE] and the physician assessed and ordered Contact Isolation [MEDICAL CONDITION] and [MEDICAL CONDITION] on 04/02/18. Although rooms were available, the facility failed to provide an appropriate room for this resident's isolation needs. Resident #149's roommate, Resident #108, independently ambulated throughout her room and the third (3rd) floor of the facility. Resident #108's Brief Interview for Mental Status (BIMS) was 04, indicating severe cognitive impairment. As Resident #108 ambulated, she encountered her roommate, visitors, staff, and other residents. Resident #108 was unable to comprehend the need for proper hand hygiene and need for infection control measures. Review of records revealed nursing notes that stated Resident #149 was picking at her wounds causing bleeding and redirection did not work. Observations noted staff were diligent about wearing a gown, gloves, and a mask with a shield every time they entered Resident #149's room. In the meantime, Resident #108 lived in this room without anything on to protect her. The facility's failure to provide appropriate infection control procedures for a resident diagnosed with [REDACTED]. A determination of immediate jeopardy situation. After consultation with the Office of Health Facility Licensure and Certification (OHFLAC) on 04/25/18 at 12:48 PM and preparation of a written statement regarding the identified deficient practice, the Administrator and Director of Nursing (DoN) were notified of this immediate jeopardy on 04/25/18 at 1:28 PM. The facility provided an acceptable Plan of Correction at 3:45 pm on 04/25/18. After determining the facility had implemented its plan of correction, the immediate jeopardy was abated on 04/25/18 at 3:53 pm The facility's Plan of Correction, received on 04/25/18 at 2:30 PM, included: Resident #149 was moved to a private room and the contact precautions continue. Resident #149 has Capacity and was reeducated by the Infection Preventionist at 2:45 PM, to avoid picking and flicking scabs and asked to inform nurses if areas are itching. DoN will evaluate Resident #108 by 3:00 PM and will discuss findings with the attending physician for any follow up. All residents of the facility have the potential to be affected. The DoN/designees conducted observation of all residents' requiring contact precautions on 04/25/18 at 1:30 PM, and no additional residents were affected. The Nurse Practice Educator (NPE)/designee will begin to re-educate all center staff on 04/25/18 regarding observation of residents in contact isolation do not expose other center residents to blood or bodily fluids with posttest to validate understanding. Staff not available during this timeframe will be provided re-education including post-test by the NPE/designee, upon returning to work. New hires will be provided education and post-test during orientation by the NPE/designee. The Unit Managers (UMS)/designee will conduct observation of residents in contact isolation daily for two weeks across all shifts including weekends, then three times a week for two weeks, then randomly thereafter to ensure that no other center residents are at risk for exposure to blood or bodily fluids of those in contact isolation. Trend identified will be reported to the DoN monthly to the Quality Improvement Committee (QIC) for any additional follow up and/or in-servicing until the issue is resolved and a randomly thereafter as determined by the QIC. After removal of the immediate jeopardy, a deficient practice, with the potential to affect more than a limited number of residents, remained at a scope and severity of E. A nurse administered medications to Resident #44 after dropping them on the medication cart, picking them up with her bare hands, and placing them in a medication cup with other medications. For Resident #99, observations of incontinence care identified breaches of technique that increased the potential for urinary tract infection. b) Resident #44 On 04/24/18 at 9:45 AM, during observation of medication administration, Licensed Practical Nurse (LPN) #40 opened five (5) oral medications for administration to Resident #44. LPN #40 dropped two (2) of the medications, [MEDICATION NAME] and Eliquis, onto the top of the medication cart. She picked up the [MEDICATION NAME] and Eliquis with her bare hands, placed them into the medicine cup along with the resident's other oral medications, and administered the medications to Resident #44. During an interview on 04/24/18 at 9:54 AM, LPN #40 stated she understood how dropping the medications on the top of the medication cart and then handling them with her bare hands could be an infection control issue. On 04/24/18 at 10:00 AM, when the observation was shared with Unit Manager (UM) #17, UM #17 made no comment regarding the matter. c) Resident #99 Observations on 04/24/18 at 11: 39 AM, noted nurse aide (NA) gathering supplies and providing incontinence care for this resident. NA Employee #86 (E#86) placed several clean, folded washcloths directly into the sink basin, shared with two (2) other residents in this room. She ran warm water from the faucet over them until they were completely submerged. E#86 squeezed out the excess water with her gloved hands, then took them to the resident's bed. The resident was incontinent of soft, semi-formed stool which was contained in the perineal and rectal areas and between her legs. [NAME] #86 at first cleaned the resident from the front to the back with one of the washcloths as the resident lay on her left side. She disposed of that washcloth into a clear, plastic bag. When E#86 got to the last washcloth, there was still bowel movement in the vulva/perineal area. She folded over the last, used wash cloth repeatedly, and made three (3) more swipes with that soiled wash cloth to remove the last of the bowel movement from the vulva and perineal area. During an interview with the director of nursing (DON) on 04/25/18 at 6:00 p.m., she said it was against the facility's policy to soak washcloths in a sink basin. She said staff were supposed to use the resident's plastic wash basin for that purpose. The DON also agreed that it was not an acceptable practice to reuse a soiled washcloth to clean the perineal area of an incontinent resident. She said she would do staff education to all staff right away. These findings were shared with the administrator on 04/26/18 at approximately 9:30 a.m. No further information was provided by the facility prior to exit.",2020-09-01
665,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,883,D,0,1,FJW311,"**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 eligible residents were offered and/or administered the pneumonia vaccinations appropriate for them. This was evident for three (3) of five (5) randomly sampled residents who were eligible to receive pneumococcal vaccinations. Resident identifiers: #99, #79, and #80. Facility census: 156. Findings include: a) Resident #99 Review of the resident's medical record on 04/25/18 found this resident entered the facility in (YEAR). There was no evidence that she received, or was offered, the Prevnar 13 and/or the [MEDICATION NAME] 23 pneumonia vaccination. b) Resident #79 Review of the medical record on 04/25/18 found this resident came to the facility in (YEAR). There was no evidence that he received, or was offered, the Prevnar 13 pneumonia vaccination. c) Resident #80 Review of the resident's medical record on 04/25/18 found this resident came to the facility in (YEAR). There was no evidence that he received, or was offered, the Prevnar 13 pneumonia vaccination. d) During an interview with nurse practice educator registered nurse Employee #167 on 04/25/18 at 4:27 p.m., she confirmed Resident #99 was eligible for the Prevnar 13 and the [MEDICATION NAME] 23 vaccinations, and that Residents #79 and #80 were eligible for the Prevnar 13 vaccination. She said she had looked for, but was unable to find, evidence the residents were offered or received the vaccinations. She showed that the facility's policy directed to offer the [MEDICATION NAME] 23 and Prevnar 13 with a twelve (12) month interval between the two (2) vaccinations. e) During an interview with the director of nursing on 04/25/18 at 6:00 p.m., the findings for these three (3) residents were discussed. All three (3) of the residents were eligible for the Prevnar 13 and/or [MEDICATION NAME] 23 vaccination, but no evidence could be provided by the nurse practice educator to verify the vaccinations were offered or given to the three (3) randomly chosen residents. f) These findings were shared with the administrator on 04/26/18 at approximately 9:30 a.m. No further information was provided by the facility prior to exit.",2020-09-01
666,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,550,D,0,1,33QL11,"Based on observation and staff interview, the facility failed to treat each resident with respect and dignity in a manner and in an environment to promote maintenance or enhancement of his or her quality of life. Resident #153's bilateral nephrostomy bags had no cover and Resident #126's urinary catheter bag had no cover. Facility census: 155. Findings included: a) Resident #153 Observation on 04/29/19 at 3:11 PM, found bilateral nephrostomy bags lying on the bed. Neither bag was covered. At this time, licensed practical nurse (LPN) #24 agreed the bags should have a cover on them. Observation of the bilateral nephrostomy bags again on 04/30/19 at 8:00 AM found no covering on either bag. At this time nurse aide (NA) #29 explained that upon completing care the bilateral nephrostomy bags had no cover. At 2:30 PM on 04/30/19, registered nurse (RN) #88 agreed the bags should be covered and would order the correct supplies. b) Resident #126 Random observation of Resident #126, on 4/30/19 at 1:10 PM, revealed the Resident's urinary catheter bag hanging under his wheelchair uncovered and had urine showing from the bag. This observation occurred in the dining room on the third floor during the lunch meal. The catheter bag was viewable by anyone entering the third-floor dining room. An interview with Nurse Aide (NA) #86 on 04/30/19 at 1:12 PM, revealed Foley catheter bags are to be covered at all times. Observed NA #86 apply a cover to Resident #126's Foley catheter bag on 04/30/19 at 1:15 PM. Assistant Director of Nursing (ADON)#122 was present at the above time on the third floor and she was asked to come to the into the dining room and she observed Resident #126's Foley catheter bag was uncovered and had urine showing from the bag. The ADON acknowledge the Foley Catheter bag needed a cover.",2020-09-01
667,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,561,D,0,1,33QL11,"Based on resident interviews, review of shower logs, and staff interviews, the facility failed to honor resident choices pertaining to the number of showers received per week, and pertaining timely assistance out of bed each morning to enable him/her to partake of breakfast in the dining room. This affected two (2) of two (2) residents reviewed for choices. Resident identifiers: #101, #36. Facility census: 155. Findings include: a) Resident #101 During resident interview on 04/30/19 at 8:41 AM Resident #101 stated she desires two (2) showers per week and is scheduled to receive two (2) showers per week. She said she rarely receives showers since her former nurse aide is no longer is assigned to her for showers. She said she could not recall the date of her last shower. Review of the most recent quarterly minimum data set (MDS), with assessment reference date (ARD 03/29/19, assessed that she required total assistance with bathing and extensive assistance with hygiene. This was also true for the former MDS with ARD 01/02/19. Review of her care plan found no evidence of her refusing care or bathing. On 04/30/19 at 4:00 PM an interview was conducted with the assistant director of nursing (ADON). She said this resident is scheduled to receive showers twice weekly on Tuesdays and Fridays. The ADON provided copies of the shower log for this resident for the months of (MONTH) and (MONTH) 2019. Per these shower log documents, out of seventeen (17) opportunities for a scheduled shower, this resident received a shower once on 03/09/19. All of the other entries in response to the question type of bath said not applicable. The ADON agreed that since only one (1) shower was documented in this two (2) month period of time, it looks like she received only one (1) shower in that time frame. She added that this resident is scheduled for a shower this evening. An interview was conducted with the administrator on 05/01/19 at 9:45 AM. She agreed that if it was not documented that a shower was taken, then a shower did not occur. b) Resident #36 During an interview on 04/29/19 at 1:11 PM, Resident #36 stated, that she likes to get up before lunch, but it does not always happen. Two (2) days ago she was told they could not get her up because the lift requires two (2) people, and they were too busy. She went on to say that they had got her before by just one (1) Nurse Aide (NA). She had to request that there always be two (2), because when it is one (1) they hurt her (she is a paraplegic). She said that the reason she wants up as early as possible because the food is hot if you get it from down stairs. During an interview on 04/30/19 at 2:37 PM, Unit Manager # was asked if two (2) people are supposed to use the lift. She answered yes. She was asked if there were times when it was done with only one person, she said, that they are not supposed to, but there has been some NA's that she has had to re-educate about always having two (2) people. She did not disagree that there were times that one person had used this lift alone. She found an education sheet that she had placed in the education and communication book. The staff are to sign the posting to indicate that they read it and understand it and there were seven (7) names on the paper. She was asked if there was more than seven people that worked on the 2nd floor she said, oh yes. She was asked if she was aware that Resident #36 was not able to get out of the bed when she wants too. She said, that no one had told her that. She said that she will make sure she gets up when she wants to.",2020-09-01
668,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,580,D,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical review, resident and staff Interviews, the facility failed to notify the physician when a wound treatment was not performed. This affected one (1)of three ( 3) residents who were reviewed for the care area of skin conditions. Resident Identifier #4. Facility Census 155. Finding included: a) Resident #4 In an interview on 04/30/19 at 4:18 PM, Resident #4 revealed she has sores on both legs, the fluid builds up, and drain out of her legs. Resident #4 said her treatment is to have her legs wrapped. Resident #4 scored a 12 on her Brief Interview for Mental Status (BIMS) on a significant change of status with an Assessment Reference Date (ARD) of 01/23/19. A score of 8-12 indicates moderately impaired cognitively. Under section B, the Resident makes self-understood is coded as understood, and the resident's ability to understand others is coded as understands clear comprehension. On 04/30/19 at 2:53 PM, Licensed Practical Nurse (LPN) #6 said the resident is taking a diuretic medication ([MEDICATION NAME] and [MEDICATION NAME])( a diuretic increase urine production in the kidneys, promoting the removal of salt and fluid from the body). LPN #6 revealed that Resident #4 has an order to have her legs wrapped every week, but the resident refuses to have her legs wrapped in the summer due to it is too hot. The LPN thought the Physical Therapy was wrapping Resident #4's legs. Observation of Resident #4's bilateral legs with LPN #6 on 04/30/19 at 3:07 PM, found the resident's legs were not wrapped. Resident's #4's legs were [MEDICAL CONDITION] and had a flaky loose scale. The LPN #6 picked up resident #4's right leg and the observation revealed an open [MEDICAL CONDITION] on the back of her leg, and knee which both were red, and weeping clear fluid. There was a brown crusty scab around the open areas. The left lower leg was excoriated red, with a hard, rough, brown scab of dried blood. There was multiple open lesion on her left leg. Observed a sheet underneath Resident #4's legs which had dried brown/burgundy stains on the sheet. LPN #6 was asked why Resident #4's legs not wrapped. LPN #6 did not make a comment. A review of Resident #4's physician order [REDACTED]. The physician order [REDACTED]. A review of Resident #4's nursing notes on 04/30/19 at 3:11 PM, found LPN #6 had documented Resident #4 had refused to have treatment to her left leg wounds on 04/24/19. A review of Treatment Administration Sheet (TAR) found no one signed off for the treatment to Resident #4's left leg wound on 04/17/19. The LPN #6 wrote refused on the TAR for 04/24/19. The record finds the Nurse Practitioner (NP) and/or the physician was not notified of Resident #4 refusing her treatment to her left leg on 04/24/19 or why the treatment was not performed as ordered on [DATE]. A review of the TAR for the right leg wound treatment found no signatures on 04/18/19 and 04/25/19. There were no notification to the NP and/or physician of why the treatment was not performed as ordered. When LPN #6 was asked why she did not notify the physician when she did not perform Resident #4 treatment to her bilateral legs on 04/24/19. LPN #6 stated that, Nurse Practitioner (NP) #157 was on duty that day. LPN #6 confirmed that she did not notify the NP that Resident #4 refused her treatment on 04/24/19. The LPN stated she did not know why Resident #4 did not receive her wound treatment to her left leg on 04/17/19. LPN #6 also acknowledge Resident #4 did not receive treatment to her right leg on 04/18/19 and 04/25/19. In an interview with NP#157 on 04/30/19 at 3:15 PM, the NP was asked whether the staff notified her Resident #4 had refused her treatment to her left leg, or the staff did not perform wound care to Resident #4's right or left leg at any time in (MONTH) 2019, the NP stated that the staff did not notify her of the wound treatment not being performed for Resident #4's right and left leg in the month of (MONTH) 2019. The Center Nurse Executive (CNE) #22 confirmed the treatment to Resident #4 was not performed by her staff as the physician ordered for the left leg on and on 04/17/19 and 4/24/19. The CNE agreed that Resident #4's right leg treatment was not performed on 04/18/19, and on 04/25/19. The CNE agreed that her staff did not notify a physician nor an NP of the Resident #4's refusal to have her treatment to her left leg and/or why they did not perform Resident #4's treatment to her right and left leg for the above dates.",2020-09-01
669,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,584,E,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, the facility failed to ensure a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Molding around the third-floor nursing desk was pulled away from the desk, and the molding was screwed back on in which it had a jagged edge. Call light outside of room [ROOM NUMBER] A room was inoperable. The third-floor shower room was leaking water from the shower drain under the flooring. The frame of wheelchair arms had ends with no covering causing bare metal with sharp edges on both arms. This had the potential to affect more than a limited number of residents. Resident Identifier: Resident #126 and #101. Other Identifiers: Third Floor Nursing desk, room [ROOM NUMBER]-A, Third Floor Shower Room. a) Nursing station Desk On 05/01/19 at 10:56 AM, the Director of Environmental Services (DES) #97, observed the molding around the third-floor nursing desk was pulled away from the desk, and the molding was screwed back on in which it had a jagged edge. The molding measured 13 inches by two (2) foot pulled away from the desk, and there were two (2) inches by three (3) inches piece of molding in which the molding was screwed down with the jagged edge. The DES acknowledges the molding needed to be fixed. b) room [ROOM NUMBER]-A Call Light On 05/01/19 at 3:31 PM, Resident #101 room [ROOM NUMBER] [NAME] said her call light does not light up outside of her room. Resident #101 was asked to push her call light so the call light could be observed whether the call light is lighting up outside of room [ROOM NUMBER]-A room. Infection Control Preventionist (ICP)#160 was walking toward 325-A's room and looked up and confirmed the call light did not light up. The ICP informed the Director of Environmental Services (DES)#97, the call light needed to be fixed. The DES came to room [ROOM NUMBER]-A and he said he will look into it right away. The DES #97 on 05/01/19 at 4:14 PM, said the light bulb needed to be replaced. Observation of room [ROOM NUMBER]-A call light outside of the room revealed the call light was in functional order now. c) Leaking water from the third-floor shower head underneath the flooring of the third-floor shower room and hallway tile floor. Observation on 5/1/19 at 2:00 PM, revealed tile in the hallway was black and gray in color outside of the third-floor shower room. A green color mat was in front of the shower door. When you opened the shower door the threshold had a towel laying in the threshold in which it was soaked with water. When you enter the shower room the flooring had water seeping out from under the flooring. An interview with the DES #97 was conducted on 5/1/19 at 3:45 PM, stated when you turn the shower head on the drain leaks water under the flooring of the shower room and continues underneath the tile in the hallway. The DES #97 said he only had knowledge of the floor leaking water underneath the flooring in the shower room and under the tile floor in the hallway for about two (2) weeks. The DES #97 said someone from (company name) is to come and fix the flooring within 30 days. The DES #97 revealed the housekeepers change the green mats around 7:00 AM, and then again about 11:00 PM, everyday. The DES #97 confirmed the nursing staff continued giving residents showers in the third-floor shower room. The DES #97 showed surveyor the housekeepers had changed the mats about an hour ago. The green mat hung over the shower room toilet. This toilet is used by the residents. The observation and feeling of the green mat revealed the mat was completely soaking wet and the DES #97 pointed at the towel which was at the threshold of the shower room and the hallway. The towel was soaked with water and very wet seeping out in the hallway across the threshold. The facility staff had one (1) yellow caution wet floor sign past the leaking water under the tile floor in the hallway. This puts residents, facility employees and the public at risk for injury. The DES #97 was asked whether he could stop all water to the main shower room on the third- floor and he said the staff told him that would make them take their resident down stairs to get a shower. He said this is a dignity issue. DES #97 said the nursing staff is having to walk and pull the resident shower Bed, and wheelchair over the wet tile floor, green mat, and the towel. The DES #97 was asked is this not dangerous and the DES #97 stated, Yes it is. The DES #97 said he was told it might be 30 days. During this time frame, the facility had knowledge of this issue and still had not corrected the problem. This procedure has the potential for residents, facility staff and the public who visit that area could slip and fall resulting in a serious injury. The wet flooring is a safety hazard the wet floor sign is not located in an area adjacent to the slippery floor area. This created a potential for individuals (residents, facility staff, and the public) to slip and fall resulting in a serious outcome. d) Leaking water from the third-floor shower head drain underneath the flooring of the third-floor shower room out into hallway tile floor. There were body and shampoo wash accessible to residents in the unlocked shower room. 1) Leaking water from the third-floor shower head drain underneath the flooring of the third-floor shower room out into hallway tile floor. Observation on 5/1/19 at 2:00 PM, revealed tile in the hallway was black and gray in color outside of the third-floor shower room. A green color mat was in front of the shower door. When you opened the shower door the threshold had a towel laying in the threshold in which it was soaked with water. When you enter the shower room the flooring had water seeping out from under the flooring. An interview with the DES #97 was conducted on 5/1/19 at 3:45 PM, stated when you turn the shower head on the drain leaks water under the flooring of the shower room and continues underneath the tile in the hallway. The DES #97 said he only had knowledge of the floor leaking water underneath the flooring in the shower room and under the tile floor in the hallway for about two (2) weeks. The DES #97 said someone from (company name) is to come and fix the flooring within 30 days. The DES #97 revealed the housekeepers change the green mats around 7:00 AM, and then again about 11:00 PM, every day. The DES #97 confirmed the nursing staff continued giving residents showers in the third-floor shower room. The DES #97 showed surveyor the housekeepers had changed the mats about an hour ago. The green mat hung over the shower room toilet. This toilet is used by the residents. The observation and feeling of the green mat revealed the mat was completely soaking wet and the DES #97 pointed at the towel which was at the threshold of the shower room and the hallway. The towel was soaked with water and very wet seeping out in the hallway across the threshold. The facility staff had one (1) yellow caution wet floor sign past the leaking water under the tile floor in the hallway. The DES #97 was asked whether he could stop all water to the main shower room on the third- floor and he said the staff told him that would make them take their resident down stairs on the elevator to get a shower. He said this is a dignity issue. DES #97 said the nursing staff is having to walk and pull the resident shower Bed, and wheelchair over the wet tile floor, green mat, and the towel. The DES #97 was asked is this not dangerous and the DES #97 stated, Yes it is. The DES #97 said he was told it might be 30 days. During this time frame, the facility had knowledge of this issue and still had not corrected the problem. This procedure has the potential for residents, facility staff and the public who visit that area could slip and fall resulting in a serious injury. The wet flooring is a safety hazard the wet floor sign is not located in an area adjacent to the slippery floor area. This created a potential for individuals (residents, facility staff, and the public) to slip and fall resulting in a serious outcome. The clinical quality specialist #155 on 05/01/19 at 5:55 PM, was informed of the water leaking from the shower head in the shower room going underneath the floor and out into the hallway on the third-floor shower room. On 05/02/19 at 8:30 AM, the Administrator of the facility confirmed that she knew about the third-floor shower room leaking water from the drain under the floor in the shower room, and out under the tile floor in the hallway for about three (3) weeks. The Administrator said she had called (company's name ) and they are to come and replace the flooring. The Administrator was asked for the information she had related to (, the repair of the floor of the third-floor shower room and hallway. The Administrator at the time of exiting the facility did not provide any information related to (company's name) coming to fix the third-floor shower room flooring and hallway tile floor. On 05/02/19 at 11:00 AM, observed a yellow caution wet floor sign in front and behind the leaking water under the hallway floor tile. There was a notice on the shower door that said Shower out of use this AM. Yellow and black tape caution criss-cross on the third-floor shower door that said caution wet floor. There were two notices near the third-floor shower hall that said, sorry in red letters, temporary closed. There was another sign saying notice in blue lettering, temporary out of service. In an interview on 05/02/19 at 11:15 AM, with the Assistant Director of Nursing (ADON) #122, said they took the shower out of use this AM. The ADON stated that, We are going to use the second-floor shower. d) Resident #126's wheelchair On 04/02/19 at 11:00 AM observation of Resident #126 found the frame located at both wheelchair arms had ends with no covering causing bare metal with sharp edges to both. Nursing assistant (NA) # 78 also observed the area and explained a new wheelchair, for this resident should be found.",2020-09-01
670,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,600,E,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, record review, and staff interviews the facility failed to ensure residents were free from any type of abuse/neglect. This was true for two (2) of three (3) Residents reviewed in the care area of abuse. Has the potential to affect all residents residing in the facility. Identified Residents #39 and #86. Facility census 155. Findings included: a) Resident # 36 During an interview on 4/29/19 at 1:24 PM, Resident #36 said, that three (3) staff members that are not allowed in her room anymore. Nurse Aide (NA) #139 was rude to her when her [MEDICATION NAME] (at surgical created stoma to drain urine from the bladder) bag busted opened. She said, that she was covered in urine. This was witnessed by a Licensed Practical Nurse (LPN) #73. She said, that the LPN came back in her room to take her statement, because she said that this incident had to be reported. She also stated that the Social Worker (SW) came to talk to her. She also stated that Licensed Practical Nurse (LPN) #16 refused to change [MEDICATION NAME] bag. It had leaked urine all over her. She said LPN #88 was always rude and snappy when she would ask her a question. She stated that she dreads it when she knows LPN #16 is going to work. She also stated that she had witnessed this same LPN #16 yell at another resident that does not know what she is doing at times. Looking for the reportable that was supposed to done on NA#139 could not be found. During a brief interview on 05/01/19 at 12:30 PM, with Registered Nurse-Unit Manager Director (RN-UM) #88, was asked if she could recall this event and if it was reported. She said yes, she gave the information to the Social (SW) #13 after the morning meeting. She was asked she filled out the, Adult Protective Services Mandatory Reporting Form. She replied no that she does not do that, she writes on a plain sheet of paper and that the SW fills those out. It this time she was also informed of the complaint about on LPN#16. During an interview on 05/01/19 at 1:45 PM, SW #13 was asked if she had completed the form for the reportable? She stated, that if she was handed any information about that she would have filled out the form and interviewed the resident. She stated that she will look again. She also informed about the complaint about LPN# 16. During a brief interview on 05/01/19 at 1:55 PM, with SW #13 stated that she cannot find where a report was done and maybe RN-UM #88 may not have given her the information. During a meeting on 05/01/19 at 2:00 PM, RN-UM #88 stated, that she remembers giving her SW # 13, the paper with the complaint on it. She was asked if she had made a copy for herself, and she replied no she did not. During a revisit on 05/01/19 at 3:25 PM, with Resident #36, SW #13 was in her room talking to her about both complaints one on NA#136 and LPN#16. b) Resident #86 During an interview on 04/30/19 at 3:09 PM, Resident # 86 said, that Rehab Tech #58 hop changed her Wheel Chair (W/C) out for a different one and it is hard for her to get herself on and off of the toilet. She stated that LPN# 16 is hateful, rude, mean and likes to quarrel about having to help her out of the W/C to use the bathroom. She said, that she tells her that she can do it herself if she wanted to and that she is just being lazy. Resident #86 stated, that she feels like she has lost her rights. Resident # 86 stated she did not tell anyone because she is at the mercy of LPN #16 and she was afraid for her life because she does not know what she would do to get back at her. During an interview on 04/30/19 at 3:24 PM, RN-UM #88 was informed of allegation of LPN#16 being rude to Resident #86 and why she did not tell anyone about it. RN-UM#88 said she was not aware of any of this. She said she knows LPN #16 does not smile but she just assumed it was just her personality. She said that this nurse would be here tomorrow if I would want to talk to her. On 05/01/19 at 4:30 PM, SW #124 informed this Surveyor that a report is being done as we speak concerning NA#136 and LPN #16. She went on to say that NA# 136 will be told not to return to work until after the investigation has been completed. She stated, the LPN# 16 is being asked to leave now until after the investigation is also completed. Also a reoportable and investigation for Resident #86. She stated that they are going to interview all residents that had received care from LPN #16. During an interview on 05/02/19 at 10:00 AM, Administrator states, that she had not rested all night thinking about Resident #36 and the NA #136 and LPN #16. She said, that has had to write both of these people up for being rude and confrontational with co-workers. She went on to say that she knows that there has been two (2) major incidents with LPN #16 but can only find one write-up. She said that she should have known if LPN#16 is rude to her co-worker then she could be rude to the Residents and that is upsetting to her. She also states that NA #136 has also been written-up for bullying, gossiping, and making verbal threats towards her peers. She was counseled on 11/07/18 and 11/21/18 the final counseling was on 11/28/18 for continuing to bully, gossip and making verbal threats. On 05/02/19 at 10:30 AM, Social Worker # 124 provided three (3) reportable completed on 05/01/19. Two (2) were from Resident #36 about NA #136 and LPN #16. One (1) was from Resident #86 about LPN #16.",2020-09-01
671,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,604,D,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to document the medical symptoms being treated by a physical restraint for one (1) of one (1) residents reviewed for the care area of restraints. Resident identifier: #67. Facility census: #155. Findings included: a) #67 Resident #67 had [DIAGNOSES REDACTED]. She had an order written [REDACTED]. On 05/02/19 at 7:50 AM, the Unit Director was informed Resident #67's restraint order did not document the medical symptoms treated by the restraint. The Unit Director stated she was not aware the medical symptoms were required to be documented. She stated Resident #67 required the seat belt restraint to allow the resident to remain seated in the wheelchair despite the medical symptoms caused by her [MEDICAL CONDITION]'s Disease. The Unit Director stated she would ensure the restraint order was revised to include the medical symptoms being treated by the restraints. No further information was provided through the completion of the survey.",2020-09-01
672,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,607,D,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Facility Policy, Resident interview, review of records and staff interview the facility failed to implement written policies and procedures that: Prohibit and prevent abuse, neglect, establish policies and procedures to investigate any such allegations. This had the potential the effect unlimited number of residents. Resident identifier: #36. Facility census 155. Findings included: a) Resident #36 Facility policy titled, OPS300 Abuse Prohibition Revision Date: 07/01/18; - Identification of possible incidents and allegation which need investigation -Investigation of incidents and allegations -Reporting of incidents, investigations, and Center response to the results of their investigations. -Initiate an investigation within 24 hours if the event does not result in serious bodily injury. During an interview on 4/29/19 at 1:24 PM, Resident #36 said, that three (3) staff members that are not allowed in her room anymore. Nurse Aide (NA) #139 was rude to her when her [MEDICATION NAME] (at surgical created stoma to drain urine from the bladder) bag busted opened. She said, that she was covered in urine. This was witnessed by a Licensed Practical Nurse (LPN) #73. She said, that the LPN came back in her room to take her statement, because she said that this incident had to be reported. She also stated that the Social Worker (SW) came to talk to her. She also stated that Licensed Practical Nurse #88 (LPN) refused to change [MEDICATION NAME] bag. It had leaked urine all over her. She said LPN #88 was always rude and snappy when she would ask her a question. She stated that she dreads it when she knows LPN #88 is going to work. She also stated that she had witnessed this same LPN #88 yell at another resident that does not know what she is doing at times. Looking for the reportable that was supposed to done on NA#139 could not be found. During a brief interview on 05/01/19 at 12:30 PM, with Registered Nurse-Unit Manager Director (RN-UM) #88, was asked if she could recall this event and if it was reported. She said yes, she gave the information to the Social (SW) #13 after the morning meeting. She was asked she filled out the, Adult Protective Services Mandatory Reporting Form. She replied no that she does not do that, she writes on a plain sheet of paper and that the SW files those out. It this time she was also informed of the complaint about on LPN#16. During an interview on 05/01/19 at 1:45 PM, SW #13 was asked if she had completed the form for the reportable? She stated, that if she was handed any information about that she would have filled out the form and interviewed the resident. She stated that she will look again. She also informed about the complaint about LPN 16. During a brief interview on 05/01/19 at 1:55 PM, with SW #13 stated that she cannot find where a report was done and maybe RN-UM #88 may not have given her the information. During a meeting on 05/01/19 at 2:00 PM, RN-UM #88 stated, that she remembers giving her SW # 13, the paper with the complaint on it. She was asked if she had made a copy for herself, and she replied no she did not. During a revisit on 05/01/19 at 3:25 PM, with Resident #36, SW #13 was in her room talking to her about both complaints one on NA#136 and LPN#13. During an interview on 04/30/19 at 3:24 PM, RN-UM #88 was informed of allegation of LPN#13 being rude to Resident #86 and why she did not tell anyone about it. RN-UM#88 said she was not aware of any of this. She said she knows LNP #13 does not smile but she just assumed it was just her personality. She said that this nurse would be here tomorrow if I would want to talk to her. On 05/01/19 at 4:30 PM, SW #124 informed this Surveyor that a report is being done as we speak concerning NA#136 and LPN #13. She went on to say that NA# 136 will be told not to return to work until after the investigation has been completed. She stated, the LPN# 13is being asked to leave now until after the investigation is also completed. Also a reportable and investigation for Resident #86. She stated that they are going to interview all residents that had received care from LPN #13.",2020-09-01
673,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,609,D,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, resident interview and staff interview the facility failed to report and investigate an alleged allegation of abuse/neglect, not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This had the potential the effect unlimited number of residents. Resident identifier: #36. Facility census 155. Findings included: a) Resident #36 Facility policy titled, OPS300 Abuse Prohibition Revision Date: 07/01/18; - Identification of possible incidents and allegation which need investigation -Investigation of incidents and allegations -Reporting of incidents, investigations, and Center response to the results of their investigations. -Initiate an investigation within 24 hours if the event does not result in serious bodily injury. During an interview on 4/29/19 at 1:24 PM, Resident #36 said, that three (3) staff members that are not allowed in her room anymore. Nurse Aide (NA) #139 was rude to her when her [MEDICATION NAME] (at surgical created stoma to drain urine from the bladder) bag busted opened. She said, that she was covered in urine. This was witnessed by a Licensed Practical Nurse (LPN) #73. She said, that the LPN came back in her room to take her statement, because she said that this incident had to be reported. She also stated that the Social Worker (SW) came to talk to her. She also stated that Licensed Practical Nurse #16 (LPN) refused to change [MEDICATION NAME] bag. It had leaked urine all over her. She said LPN #88 was always rude and snappy when she would ask her a question. She stated that she dreads it when she knows LPN #16 is going to work. She also stated that she had witnessed this same LPN #88 yell at another resident that does not know what she is doing at times. Looking for the reportable that was supposed to done on NA#139 could not be found. During a brief interview on 05/01/19 at 12:30 PM, with Registered Nurse-Unit Manager Director (RN-UM) #88, was asked if she could recall this event and if it was reported. She said yes, she gave the information to the Social (SW) #13 after the morning meeting. She was asked she filled out the, Adult Protective Services Mandatory Reporting Form. She replied no that she does not do that, she writes on a plain sheet of paper and that the SW files those out. It this time she was also informed of the complaint about on LPN#16. During an interview on 05/01/19 at 1:45 PM, SW #13 was asked if she had completed the form for the reportable? She stated, that if she was handed any information about that she would have filled out the form and interviewed the resident. She stated that she will look again. She also informed about the complaint about LPN# 16. During a brief interview on 05/01/19 at 1:55 PM, with SW #13 stated that she cannot find where a report was done and maybe RN-UM #88 may not have given her the information. During a meeting on 05/01/19 at 2:00 PM, RN-UM #88 stated, that she remembers giving her SW # 13, the paper with the complaint on it. She was asked if she had made a copy for herself, and she replied no she did not. During a revisit on 05/01/19 at 3:25 PM, with Resident #36, SW #13 was in her room talking to her about both complaints one on NA#136 and LPN#16.",2020-09-01
674,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,623,D,0,1,33QL11,"Based on staff interview and record review, the facility failed to notify the ombudsman of acute transfers to the hospital. This has the potential to affect two of two residents who had been transferred to the hospital for various reasons and no notice was sent to the ombudsman. The resident identifiers are: #145 and #139. Facility census: 155. Findings included: a) Resident #145 The resident was sent to the hospital for stomach issues resulting in nausea and vomiting. Resident stated during an interview on 5/1/19 that he had been to the hospital recently because his stomach was messed up but he did not have to have surgery. It was found there had been a bowel obstruction. Did not find that information was provided to the local Ombudsman that the resident had been transferred to the hospital. Other information had been given such as bed hold, reason for transfer, etc. but not Ombudsman notification. On 05/02/19 at 11:22 AM Interview with Employee #155 and she stated the social work staff had not been providing discharge information to the ombudsman. The staff had been sending a notice of the residents who had been discharged to home, but not the acute care transfers . They would have to start doing this in the immediate future. b) Resident #157 Resident #157's was discharged to Hospice care on 02/18/19. Review of medical records found no evidence the facility completed a a notice of discharge to the resident/resident representative in writing. On 05/01/19 at 2:25 PM coordinator-clinical reimbursement (CCR) #47 agreed the records did not obtain evidence the facility completed a notice of discharge in writing, for the family.",2020-09-01
675,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,641,D,0,1,33QL11,"**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 a minimum data set (MDS) assessment related to medications the resident received in the look-back period. This was evident for one (1) of five (5) residents reviewed for unnecessary medications out of thirty-one (31) sampled residents. Resident identifier: #44. Facility census: 155. Findings include: a) Resident #44 On 04/30/19 medical record review revealed this resident was an insulin-dependent diabetic. Current physician's orders [REDACTED]. The latter had a parameter to hold the [MEDICATION NAME] if the blood sugar was less that 150 milligrams per deciliter (mg/dl). Review of the most recent minimum data set (MDS) with assessment reference date (ARD) 02/21/19, found she was assessed as having received no insulin injections during the last seven (7) days. Further review of the medical record found physician orders [REDACTED]. Per the (MONTH) 2019 Medication Administration Record [REDACTED]. Another physician's orders [REDACTED]. It had a parameter to hold the [MEDICATION NAME] for a blood sugar of less than 150 mg/dl. Review of the (MONTH) MAR indicated [REDACTED]. An interview was conducted with the director of nursing (DON) on 04/30/19 at 3:00 PM. It was discussed that section N of the 02/21/19 MDS assessed this resident received no insulin injections in the seven (7) day look-back period. The DON agreed this was in error. On 05/01/19 at 9:45 AM an interview was conducted with the administrator. The 02/21/19 MDS error related to insulin usage was discussed. She spoke her understanding. An interview was conducted with MDS registered nurse #25 (RN #25) on 05/01/19 at 10:00 AM. She said she was informed yesterday of the incorrect entry in section N of the 02/21/19 MDS as it related to the number of days this resident received insulin injections in the seven (7) day look-back period. She said she originally entered zero days, and this was in error. She said she now made a modification of that entry to correctly capture that the resident received insulin injections daily in the seven (7) look-back period.",2020-09-01
676,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,656,E,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and record review the facility failed to develop and/or implement the comprehensive care plan in the areas of, nephrostomy bags care, following a residents snack of choice, contracture care, and suprapubic catheter care. This is true for four (4) of thirty-one (31) residents reviewed. Resident identifiers: #153, #87, and #130. Facility census: 155. Findings included: a) Resident #153 Review of the current care plan in the area of risk for complications related to bilateral nephrostomy tubes includes an intervention to record nephrostomy tube output. The current physician order [REDACTED]. Nephrostomy drainage out-put documentation, reveals the facility did not meet the physician ordered parameters fourteen (14) of of twenty (20) days beginning 04/09/19 and ending 04/28/19. On 05/01/19 at 9:35 AM clinical quality specialist (CQS) #155 agreed the documentation of nephrostomy drainage out-put did not meet the order specified by the physician. b) Resident #130 Observation on 04/29/19 at 3:57 PM revealed this resident with bilateral contractures of the hands with no devices in place. Review of the medical record revealed he has palm protectors ordered. Observation on 05/01/19 at 5:00 PM found a folded washcloth in his right hand. He used a communication board to say they keep a supply of washcloths in his bedside stand. During an interview with his nurse aide #14 (NA #14) at this time, she said they use a washcloth in the right hand only. She said she thought this was because the index finger on his right hand was bent downward and inward, and they were trying to protect the skin integrity of his palm. Review of the medical record on 05/01/19 at 5:30 PM found current physician orders [REDACTED]. Wear As Tolerated. Remove For Hygiene. every day and night shift. Review of the care plan on 05/01/19 at 5:30 PM revealed an intervention initiated 04/15/19 as follows: {Typed as written} Palm Protectors With Finger Separators to Right Hand. Wear As Tolerated. Remove For Hygiene. An interview was conducted with licensed nurse #140 (LPN #140) on 05/01/19 at 5:43 PM. She said they use a washcloth in his right hand, not a palm guard with finger separators. She said he has no wounds of any type at this point in time. An interview was conducted with occupational therapy employee #152 (COTA #152) on 05/02/19 at 8:00 AM. She said they (therapy) recommended he use a palm protector with finger separators if tolerated. If not tolerated, she said that he can use washcloths. She was informed that he was care planned for the palm protector with finger separators to the right hand, not the wash cloth, yet staff were using only a washcloth. Relayed that nothing is used in the left hand. She said she would speak with the therapy director about this, who in turn will be in contact with nursing. An interview with the assistant director of nursing (ADON) and the corporate quality services registered nurse #155 (CQS #155) on 05/02/19 at 12:45 PM found that a new order from the physician was entered into the electronic medical record (EHR) this morning for a washcloth to the right hand. The ADON said she revised the care plan today to reflect that change. At approximately 1:00 PM on 05/02/19 the director of nursing (DON) provided a copy of a verbal physician order [REDACTED].{typed as written} Resident To Have Wash Cloth in right Hand as tolerated. (MONTH) Remove For Skin Checks & (symbol for and) Hygiene. The start date for this order was the 7 a - 3 p shift on 05/02/19. c) Resident #87 10:00 AM Snack A review of Resident #87's Significant Minimum Data Set (MDS) with an assessment 03/19/19 finds Section B hearing, speech, and vision make self-understood, has the ability to express ideas, wants, consider both verbal and nonverbal expression is coded as understood. Resident #87 ability to understand others, understands verbal content, is coded as understands-clear comprehension. Under Section F, interview for daily preference, D. How important is it to you to have snacks available between meals is coded as it is very important. A review of Resident #87's care plan on 05/01/19 at 8:20 AM, found an intervention to provide snacks twice a day (BID) at 10:00 AM, and 8:00 PM, (cottage cheese and assorted half of a sandwich). The Kardex ( It was meant to serve as a quick reference for nurses when they wanted to know what care a patient needed )for the Nurse Aide (NA) found the NA is to provide a snack BID at 10:00 AM and 8: 00 PM (cottage cheese and assorted half sandwich). On 05/01/19 at 9:30 AM, Resident #87 was in her recliner chair on the third-floor dining room. While waiting to see if Resident #87 would receive her 10:00 AM snack, Resident #87 was interviewed at this time. Resident #87 stated, she likes to have a coke first thing in the morning and in the afternoon before her nap. She said it is super. Resident #87 on 05/01/19 at 9:55 AM, asked the surveyor to reposition her legs. Housekeeper #55 was in the dining room and the surveyor asked the Housekeeper to get someone from the Nursing department to come and help Resident #87 reposition her legs. The clinical reimbursement coordinator (CRC) came in and reposition her legs. The CRC did not ask Resident #87 if she wanted something to drink or to offer her 10:00 AM snack. The resident said at 10:00 AM, I like to have a coke. On 05/01/18 at 10:17 AM, Nurse Aide, #78 came into the dining room and looked around and left the room. The NA #78 did not offer Resident #78 her 10:00 AM snack or something to drink. On 05/01/19 at 10:24 am, Resident #87 stated that I like to have a coke or orange juice. Do you think they put away the orange juice yet? The Resident #87 said on 05/01/19 at 10:31 AM, will you get me a coke, I am really dry. The Assistant Director of Nursing (ADON) on 05/01/19 at 10:34 AM, was informed the Resident #87 did not receive her 10:00 AM snack. The ADON was informed Resident #87 like to know if she could have a Coke. The ADON said the staff did not give (resident name )Resident #87, 10:00 AM snack. Licensed Practical nurse (LPN) #140, on 05/01/19 at 10:35 AM, turned around in her chair at the nursing desk on the third floor and stated, I bring her a coke every day I work, it is in her room. I will go and get the coke and give her some now. LPN #140 on 05/01/19 at 11:00 AM, revealed, she went and gave Resident #87 graham crackers and some Coke to drink.",2020-09-01
677,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,657,D,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise the comprehensive care plan for two (2) out of 31 for the area of food preference and [MEDICATION NAME] use. This has the potential to affect less than a limited number of residents. Resident Identifiers #87 and #17. Facility Census 155. Findings included: a) Resident #87 A review of Resident #87's care plan on 05/01/19 at 8:05 AM, finds a care plan with a focus of while in the facility, (resident's first name) Resident #87, states that it is important that she has the opportunity to engage in daily routines that are meaningful relative to her preferences. created on 12/05/18, and revised on 12/12/18. The focus is I like to snack between meals and prefer beaver tails and cheese its.(sic) This intervention was initiated on 12/05/19. A review of Resident #87's participation record finds the resident is not offered beaver tails or Cheez It. on her preferences and interests. The recreation director (RD) #118, on 05/01/19 at 8:15 AM, said Resident# 87 likes someone to read to her, talk about just about anything. The RD said she does most one (1) on one (1) activities with Resident #87. The RD said she had tried crafts, but this does not work. The RD was asked whether she provides beaver tails to Resident #87. The RD stated, What is that. A beaver tail is: a fried dough pastries, individually hand stretched to resemble beaver's tails. The RD confirmed the facility does not give Resident #87 beaver tails. The Assistant Director of Nursing (ADON) #122 on 05/01/19 at 11:15 AM, was asked do you provide a snack called beaver tails and cheese it's to Resident #87. The ADON said what is a beaver tail. The ADON said they do give the resident cheez-it. The Food Service Director (FSD) #154 on 05/01/19 at 12:14 PM, was asked whether she gives beaver tails to the activity department to give to Resident #87. The FSD stated that she did not know what a beaver tail was. b) Resident #17 Review of the care plan on 04/30/19 found a problem of, risk for injury, bruising, or complications related to the use of anticoagulation therapy. Continued review of medical records found a physician order [REDACTED]. to discontinue [MEDICATION NAME] (anticoagulant) due to bleeding [MEDICAL CONDITION] lesion on scalp, advanced age and unable to draw labs. On 05/01/19 at 3:35 PM clinical quality specialist (CQS) agreed the care plan was not revised and presented the care plan with the corrected revision.",2020-09-01
678,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,677,D,0,1,33QL11,"Based on observation, resident interview, and staff interview the facility failed to meet the activity of daily living (ADL) need for Resident #19 related to hygiene care of a contracture. This is true for one (1) of two (2) residents reviewed. Facility census: 155. Findings included: a) Resident #19 On 04/30/19 at 8:30 AM a request was made for registered nurse (RN) #88 to open the contractured left hand of Resident #19. While opening the hand there was a strong odor, the palm had an indentation from the nail on the ring finger, and the nail needed to be trimmed. Resident nurse #88 agreed the left hand needed cleaned and the nail cut. She completed both within a few minutes.",2020-09-01
679,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,684,E,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Staff interview, Policy review and Resident council meeting, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, By Pre-pulling their medications and placing them inside a draw in the medication cart. this was a random opportunity for discovery. Identified Resident's# 89, #30, #10, #77, #84, #128 and #66. Resident #116 waiting for an extended time for Activities of Daily Living (ADL) care. Resident #108 antibiotics was not completed as per physician orders, Resident #154 did not have weights or labs as per the physician orders. Resident #78 fingerstick was not completed as per the physician orders. Resident #140 did not receive nebulizer treatment according to physician orders. Resident #130 did not have contracture treatment as per physician orders. Resident #44 did not follow physician orders for blood glucose testing Resident #4 did not receive wound care treatment per the physician orders. This was true for 15 of 31 reviewed in the survey. Facility census 155. Findings included: a) Resident #89 During an observation on 05/01/19 at 10:38 AM, Licensed Practical Nurse (LPN) #64 had pre-pulled the medications for Resident # 89 in the top draw of the medication cart he was using that day. He was asked about these cups of medications. He stated, that the resident was not in their room and that is why the cups of medications were in his cart. He was asked what he was going to do with the medication that he had pre-pulled. He stated that he was going to discard them. He was then asked if he was going to waste them than why had he took the time to write the room number and bed letter on each cup of medication. He said, well I guess you got me on that one b) Resident #30 During an observation on 05/01/19 at 10:38 AM, Licensed Practical Nurse (LPN) #64 had pre-pulled the medications for Resident # 30 in the top draw of the medication cart he was using that day. He was asked about these cups of medications. He stated, that the resident was not in their room and that is why the cups of medications were in his cart. He was asked what he was going to do with the medication that he had pre-pulled. He stated that he was going to discard them. He was then asked if he was going to waste them than why had he took the time to write the room number and bed letter on each cup of medication. He said, well I guess you got me on that one c) Resident #10 During an observation on 05/01/19 at 10:38 AM, Licensed Practical Nurse (LPN) #64 had pre-pulled the medications for Resident # 10 in the top draw of the medication cart he was using that day. He was asked about these cups of medications. He stated, that the resident was not in their room and that is why the cups of medications were in his cart. He was asked what he was going to do with the medication that he had pre-pulled. He stated that he was going to discard them. He was then asked if he was going to waste them than why had he took the time to write the room number and bed letter on each cup of medication. He said, well I guess you got me on that one d) Resident #77 During an observation on 05/01/19 at 10:38 AM, Licensed Practical Nurse (LPN) #64 had pre-pulled the medications for Resident # 77 in the top draw of the medication cart he was using that day. He was asked about these cups of medications. He stated, that the resident was not in their room and that is why the cups of medications were in his cart. He was asked what he was going to do with the medication that he had pre-pulled. He stated that he was going to discard them. He was then asked if he was going to waste them than why had he took the time to write the room number and bed letter on each cup of medication. He said, well I guess you got me on that one e) Resident #84 During an observation on 05/01/19 at 10:38 AM, Licensed Practical Nurse (LPN) #64 had pre-pulled the medications for Resident # 84 in the top draw of the medication cart he was using that day. He was asked about these cups of medications. He stated, that the resident was not in their room and that is why the cups of medications were in his cart. He was asked what he was going to do with the medication that he had pre-pulled. He stated that he was going to discard them. He was then asked if he was going to waste them than why had he took the time to write the room number and bed letter on each cup of medication. He said, well I guess you got me on that one f) Resident #128 During an observation on 05/01/19 at 10:38 AM, Licensed Practical Nurse (LPN) #64 had pre-pulled the medications for Resident # 128 in the top draw of the medication cart he was using that day. He was asked about these cups of medications. He stated, that the resident was not in their room and that is why the cups of medications were in his cart. He was asked what he was going to do with the medication that he had pre-pulled. He stated that he was going to discard them. He was then asked if he was going to waste them than why had he took the time to write the room number and bed letter on each cup of medication. He said, well I guess you got me on that one g) Resident #66 During an observation on 05/01/19 at 10:38 AM, Licensed Practical Nurse (LPN) #64 had pre-pulled the medications for Resident # 66 in the top draw of the medication cart he was using that day. He was asked about these cups of medications. He stated, that the resident was not in their room and that is why the cups of medications were in his cart. He was asked what he was going to do with the medication that he had pre-pulled. He stated that he was going to discard them. He was then asked if he was going to waste them than why had he took the time to write the room number and bed letter on each cup of medication. He said, well I guess you got me on that one h) Resident #140 The facility failed to follow physician's orders for nebulizer administration. The physician ordered albuteral nebulizer treatments every four (4) hours. The order was transcribed incorrectly on 04/23/19 instead to every four (4) hours as needed. From 04/23/19 through 04/30/19 she received only three (3) albuteral neb treatments as follows: 04/23/19 at 2045; 04/24/19 at 10 AM; 04/26/19 at 8:40 AM. The medical record was reviewed on 05/01/19. Resident #140 has [MEDICAL CONDITIONS]. Prior to a (MONTH) 2019 hospitalization , she had physician orders for [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) nebulizer treatments every four (4) hours for dyspnea, wheezing, and cough. Review of the medication administration record(MAR) for early (MONTH) pre-hospitalization dates found she took it around the clock with few exceptions. Review of the hospital discharge summary dated 03/28/19 found that the hospital recommended that she continue the same nebulizer treatments upon return to the nursing home. Review of the facility's physician order sheet and interim plan of care dated 03/28/19 contained orders for Albuteral nebulization treatments every four (4) hours for shortness of breath. The facility physician signed those orders on 03/29/19. Review of the March, 2019 MAR found an order for [REDACTED]. Review of the (MONTH) 2019 MAR found she continued to receive albuteral nebulization treatments every four (4) hours which she consistently accepted. Further review of the (MONTH) 2019 MAR found that the facility changed over to electronic health records (EHR) on 04/23/19 in the evening. The EHR MAR indicated [REDACTED]. Review of the (MONTH) MAR from 04/24/19 through 04/30/19 found she received only two (2) albuteral nebulization treatments. One occurred at 10 AM on 04/24/19, and the other occurred on 04/26/19 at 8:40 AM. An interview was conducted with the corporate quality services registered nurse #155 (CQS #155) and the director of nursing (DON) on 05/01/19 at 2:30 PM. It was discussed that on 03/28/19 instead of the [MEDICATION NAME] ([MEDICATION NAME]-albuteral), the nurse who reconciled the orders instead wrote only albuteral nebulization treatments. According to the manufacturer's guidelines, this delivered .5 milligrams less Albuteral than did the [MEDICATION NAME]. The CQS and DON said the physician signed the re-admission orders [REDACTED]. The CQS said that a transcription error must have occurred when the facility switched to EHR on 04/23/19, which led to the resident receiving the Albuteral nebulization treatments only every four (4) hours prn (as needed) rather than every four (4) hours around the clock as the physician ordered. An interview was conducted with the CQS and nurse practitioner #158 (NP #158) on 05/01/19 at 2:45 PM. They said there were no physician orders to discontinue the Albuteral nebulization treatments ordered every four (4) hours. They said there were no new physician orders to administer Albuteral nebulization treatments every four (4) hours prn. The CQS agreed that the facility failed to follow physician orders for the Albuteral nebulizer treatments every four (4) hours following the 04/23/19 change over to EHR system. NP #158 said she will assess the resident today, and see if the resident is able and agreeable with keeping the nebulization treatments every four (4) hours prn. i) Resident #130 Observation on 04/29/19 at 3:57 PM revealed this resident with bilateral contractures of the hands with no devices in place. Review of the medical record revealed he has palm protectors ordered. Observation on 05/01/19 at 5:00 PM found a folded washcloth in his right hand. He used a communication board to say they keep a supply of washcloths in his bedside stand. During an interview with his nurse aide #14 (NA #14) at this time, she said they use a washcloth in the right hand only. She said she thought this was because the index finger on his right hand was bent downward and inward, and they were trying to protect the skin integrity of his palm. Review of the medical record on 05/01/19 at 5:30 PM found current physician orders as follows: {typed as written} Palm Protectors With Finger Separators to Right Hand. Wear As Tolerated. Remove For Hygiene. every day and night shift. Review of the care plan on 05/01/19 at 5:30 PM revealed an intervention initiated 04/15/19 as follows: {Typed as written} Palm Protectors With Finger Separators to Right Hand. Wear As Tolerated. Remove For Hygiene. An interview was conducted with licensed nurse #140 (LPN #140) on 05/01/19 at 5:43 PM. She said they use a washcloth in his right hand, not a palm guard with finger separators. She said he has no wounds of any type at this point in time. An interview was conducted with occupational therapy employee #152 (COTA #152) on 05/02/19 at 8:00 AM. She said they (therapy) recommended he use a palm protector with finger separators if tolerated. If not tolerated, she said that he can use washcloths. She was informed that he was care planned for the palm protector with finger separators to the right hand, not the wash cloth, yet staff were using only a washcloth. Relayed that nothing is used in the left hand. She said she would speak with the therapy director about this, who in turn will be in contact with nursing. An interview with the assistant director of nursing (ADON) and the corporate quality services registered nurse #155 (CQS #155) on 05/02/19 at 12:45 PM found that a new order from the physician was entered into the electronic medical record (EHR) this morning for a washcloth to the right hand. The ADON said she revised the care plan today to reflect that change. At approximately 1:00 PM on 05/02/19 the director of nursing (DON) provided a copy of a verbal physician order dated 05/01/19 at 10:49 PM which stated the following: {typed as written} Resident To Have Wash Cloth in right Hand as tolerated. (MONTH) Remove For Skin Checks & (symbol for and) Hygiene. The start date for this order was the 7 a - 3 p shift on 05/02/19. j) Resident #44 The medical record was reviewed on 04/30/19. Review of the recapitulation of physician's orders for (MONTH) and (MONTH) 2019 found physician orders to administer [MEDICATION NAME] Insulin ten (10) units subcutaneously with meals related to diabetes mellitus. It included directives to withhold the insulin if the blood sugar was less than 150 milligrams/deciliter (mg/dl). Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Per physician's orders, the insulin should have been withheld. However, the nurse administered ten (10) units of [MEDICATION NAME] insulin. Also, at 7:30 AM on 04/24/19 and on 04/25/19 the space in which to document the blood sugar results and the administration of insulin was left blank. During an interview with the director of nursing (DON) on 04/30/19 at 3:00 PM, it was discussed that the resident received ten (10) units of [MEDICATION NAME]on 04/26/19 at 7:30 AM when the blood sugar was only 106 mg/dl. She agreed that the insulin should have been withheld. It was also discussed that at 7:30 AM on 04/24/19 and on 04/25/19 there was no evidence as to the blood sugar result and/or if the insulin was given or was held. The DON agreed and offered no further explanation. An interview was conducted with the administrator on 05/01/19 at 9:45 AM. She was informed that on 04/26/19 at 7:30 AM this resident received insulin when she had a blood sugar reading of 106 mg/dl. It was discussed that the physician set a parameter directing to not give the insulin with meals when the blood sugar was less than 150 mg/dl. It was also discussed that there was no evidence on 04/24/19 and 04/25/19 at 7:30 AM if the nurse followed the physician's order to assess the blood sugar at that time and administer insulin. No further information was provided prior to exit. k) Resident #4 In an interview on 04/30/19 at 4:18 PM, Resident #4 said she has sores on both legs, the fluid builds up, and drain out of her legs. Resident #4 said her treatment is to have her legs wrapped. Resident #4 scored a 12 on her Brief Interview for Mental Status (BIMS)on a significant change of status. 01/23/19. A score of 8-12 indicates moderately impaired cognitively. Under section B, the Resident makes self-understood is coded as understood, and the resident's ability to understand others is coded as understands clear comprehension. On 04/30/19 at 2:53 PM, Licensed Practical Nurse (LPN) #6 said the resident is taking a diuretic medication ([MEDICATION NAME] and [MEDICATION NAME])( a diuretic increase urine production in the kidneys, promoting the removal of salt and fluid from the body). LPN #6 revealed that Resident #4 has an order to have her legs wrapped every week, but the resident refuses to have her legs wrapped in the summer due to it is too hot. The LPN thought the Physical Therapy was wrapping Resident #4's legs. Observation of Resident #4's bilateral legs with LPN #6 on 04/30/19 at 3:07 PM, found the resident's legs were not wrapped. Resident's #4's legs were [MEDICAL CONDITION] and had a flaky loose scale. The LPN #6 picked up resident #4's right leg and the observation revealed an open [MEDICAL CONDITION] on the back of her leg, and knee which both were red, and weeping clear fluid. There was a brown crusty scab around the open areas. The left lower leg was excoriated red, with a hard, rough, brown scab of dried blood. There was multiple open lesion on her left leg. Observed a sheet underneath Resident #4's legs which had dried brown/burgundy stains on the sheet. LPN #6 was asked why Resident #4's legs not wrapped. LPN #6 did not make a comment. A review of Resident #4's physician order dated 03/13/19. The physician order states to cleanse venous ulcer to left lateral leg with wound cleanser pat dry, apply Optilock and wrap with fourflex wraps every seven (7) days and whenever needed (PRN). The physician order for [REDACTED]. A review of Resident #4's nursing notes on 04/30/19 at 3:11 PM, found LPN #6 had documented Resident #4 had refused to have treatment to her left leg wounds on 04/24/19. A review of Treatment Administration Sheet (TAR) found no one signed off for the treatment to Resident #4's left leg wound on 04/17/19. The LPN #6 wrote refused on the TAR for 04/24/19. The record finds the Nurse Practitioner (NP) and/or the physician was not notified of Resident #4 refusing her treatment to her left leg on 04/24/19 or why the staff did not follow the physician order to treat Resident #4's left leg on 04/17/19. A review of the TAR for the right leg wound treatment found no signatures on 04/18/19 and 04/25/19. There were no notification to the NP and/or physician of why the treatment was not performed as ordered. When LPN #6 was asked why she did not follow the physician order for [REDACTED].#6 stated that, Nurse Practitioner (NP) #157 was on duty that day. LPN #6 confirmed that she did not notify the NP that Resident #4 refused her treatment on 04/24/19. The LPN stated she did not know why Resident #4 did not receive her wound treatment to her left leg on 04/17/19. LPN #6 also acknowledge Resident #4 did not receive treatment to her right leg on 04/18/19 and 04/25/19. In an interview with NP# 157 on 04/30/19 at 3:15 PM, the NP was asked whether the staff informed her Resident #4 had refused her treatment to her left leg, or the staff was not following the physician order to treat Resident #4's right or left leg at any time in (MONTH) 2019, the NP stated that, the staff did not notify her of the wound treatment not being done for Resident #4's right and left leg for the month of (MONTH) 2019. The Center Nurse Executive (CNE) #22 confirmed the treatment to Resident #4 was not performed by her staff as the physician ordered for the left leg on 04/17/19 and 4/24/19. The CNE agreed that Resident #4's right leg treatment was also not performed on 04/18/19 and 04/25/19. The CNE agreed that her staff did not notify a physician nor an NP of the resident's refusal to have her treatment to her left leg and/or why they did not follow the physician order to performed Resident #4's treatment to her right and left leg for the above dates. l) Resident #116 During Resident Council meeting on 04/30/19 at 10:00 AM Resident #116, whom has an intact cognitive ability, expressed a concern with staff answering call bells timely. At times there is a forty-five (45) minute wait after pressing the call bell before staff responds to assist in changing a soiled brief. Nine other residents at the meeting agreed call bells are often not answered in a timely manner. m) Resident #108 Resident #108 had an order written [REDACTED]. Ten (10) days of antibiotics twice a day meant Resident #108 should have received 20 doses of [MEDICATION NAME]. Review of Resident #108's Medication Administration Record [REDACTED]. During an interview on 05/01/19 at 5:58 PM, the Unit Director and the Facility Director of Nursing confirmed Resident #108's MAR indicated [REDACTED]. No further information was provided through the completion of the survey. n) Resident #154 Resident #154 was admitted to the facility 04/11/19. Resident #154 received total [MEDICATION NAME] nutrition (TPN) therapy, a method of infusing fluids into a vein to bypass the gastrointestinal tract and provide nutrients needed. Resident #154 had the following orders: - Weigh every day shift, every Thursday, written on 04/11/19, to start 04/18/19 - Weigh one time a day, every 7 day(s) for monitor for 4 weeks until finished, written on 04/23/19, to start 04/23/19, to end 05/21/19 Review of Resident #154's medical records revealed the only weight recorded for the resident was an admission weight on 04/11/19. During an interview on 05/01/19 at 11:42 AM, Corporate Quality Services Registered Nurse verified Resident #154's weight had not been recorded since admission. She stated Resident #154's weight would be obtained immediately. Resident #154 also had an order for [REDACTED]. Review of Resident #154's medical records revealed no laboratory testing performed on 04/15/19. Laboratory testing consisting of a complete blood count and comprehensive metabolic panel was performed on 04/16/19. During an interview on 05/01/19 at 3:15 PM, the Director of Nursing confirmed Resident #154 did not have laboratory testing on 04/15/19. She stated Resident #154 did have laboratory testing performed on 04/16/19 but confirmed this laboratory testing did not include a magnesium level and phosphorus level as ordered by the physician to be performed weekly. No further information was provided through the completion of the survey. o) Resident #78 Resident #78 had an order written [REDACTED]. (Order typed as written.) [MEDICATION NAME] is an antipsychotic medication that can cause elevated blood glucose levels. An Accu-Check test involves the nurse obtaining a drop of blood from the resident's fingertip to check the blood glucose level. Review of Resident #78's Medication Administration Record [REDACTED]. Resident #78's progress notes did not document a blood glucose level for 05/01/19. On 05/02/19 at 11:15 AM, Licensed Practical Nurse (LPN) #200 confirmed Resident #78's monthly blood glucose monitoring was not recorded for 05/01/19. On 05/02/19 at 11:20 AM, the Unit Director confirmed Resident #78's monthly blood glucose monitoring was not recorded for 05/01/19. No further information was provided through the completion of the survey.",2020-09-01
680,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,686,D,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and facility policy review, the facility failed to provide pressure ulcer treatment according to professional standards of practice, to promote healing, prevent infection. This was true for two (2) of three (3) reviewed for the care area of pressure ulcers. Identified Residents #136 and #36 Facility census 155. Findings included: a) #136 During an interview on 04/29/19 at 11:32 AM, Resident #136 said that he had sore on buttock. He was asked if the staff came in on a regular basis to two him every two hours. This resident was in a boating accident and suffered a stroke. He was left unable to use his legs and his left arm. He stated that the staff does not help to change his positions every two (2) hours. During an observation on 05/01/19 at 2:23 PM, Licensed Practical Nurse (LPN) # 13 provide wound care for Resident #136 no the buttock. LPN #13 appeared to be unsure of what to do she repeatedly looked to the Registered Nurse Unit Manager (RNUM) # 88 for guidance. RNUM #88 was prompting LPN#13 to wash her hands, intervening and instructing this nurse on how to provide the wound care. During an interview on 04/29/19 at 12:10 PM, RNUM #88 agreed that she had intervened and provided instruction. She also agreed that if she had not the LPN would not have provided care to meet the professional standards. b) Resident #36 During an interview on 04/29/19 at 1:35 PM, Resident #36 stated, that she had pressure ulcers on her buttock and both feet. This resident was a paraplegic. She stated that she has to call for someone to turn her at night, but it is not every two (2) hours. During an observation on 05/02/19 at 7:52 AM, LPN #103 was removing the dressings on the buttock on Resident #36 when the RN-UM #88 prompted LPN #103 to remove the dressing from the left shoulder area before the ones on the buttock area, then again the clean the area on the shoulder first and to wash her hand. Surveyor intervention stopped LPN# 103 from repeated use of a gauze used to clean the wounds using the front and back of the gauze and on only one wound. RN-UM #88 intervened to explain how to apply the dressing on the left gluteal fold. LPN #103 told NA #43 to hold the absorbent pad in place while she opened dressing NA #43 did it without thinking about changing his gloves as he should have. LPN #103 asked if she should wash her hands more than once, she was not organized taking longer than it should have taken. Resident # 36 reminded her that she had not had anything to eat yet. It was 9:08 AM, instead of setting up as her table with all the items she would need to use for each wound site she fumbled around and repeatedly asked for RN-UM #88 to open things. Areas were the left shoulder, multiple Pressure wounds on the buttock and gluteal folds, left and right foot. Resident # 36 instructed LPN#103 on how to change her [MEDICATION NAME]. During a post procedure interview on 05/02/19 at 9:23 AM, LPN #103 stated, that she thought she did very well. When the many problems were pointed out she stated that she does not normally care for this resident. During an interview on 05/02/19 at 9:25 AM, RN-UM # 88 stated that she thought LPN# 103 could have done better, but in her defense night shift normally do the dressing. She did agree that LPN #13 and LPN #103 should have the skill set to perform these tasks without prompting and intervention. c) Facility policy Facility policy titled, Wound Dressing: Aseptic Revision Date: 11/28/17 included: -Prepared label with date and initials. -If patient has multiple wounds: Treat less contaminated wound first -In separate locations: Treat each as a separate procedure",2020-09-01
681,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,689,E,0,1,33QL11,"Based on observation, staff interview and record review the facility failed to provide an environment as free of accident hazards as possible, over which the facility had control. The facility failed to keep mattress cover straps off the floor, failed to maintain safe maintenance on a wheelchair, failed to hang a trapeze bar in a safe manner, failed to repair a leak in the shower causing water to enter the hallway and failed to keep bodywash/shampoo contained in an area safe from residents. Resident identifiers: #153, #126, and #136. Facility census: 155. Findings include: a) Resident #153 Observation on 04/29/19 at 3:11 PM found four yellow straps hanging from residents bed. These are used to hold a mattress cover in place. The two straps on the right side of the bed just touched the floor and two on the left side of the bed had at least two feet of strap on the floor. At this time, Licensed nurse (LPN) #24 placed the straps in a safe position and agreed the strapping should be contained under the mattress and off the floor. On 04/30/19 at 8:00 AM the two straps on the left side of the bed were again, in the same position on the floor. Nursing assistant #29 agreed the straps should be contained under the mattress. b) Resident #126 On 04/02/19 at 11:00 AM observation of Resident #126's wheelchair found the frame located at both wheelchair arms had ends with no covering causing bare metal with sharp edges exposed on both. Nursing assistant (NA) # 78 also observed the area and explained a new wheelchair, for this resident, should be found. d) Leaking water from the third-floor shower head drain underneath the flooring of the third-floor shower room out into hallway tile floor. There were body and shampoo wash accessible to residents in the unlocked shower room. 1) Leaking water from the third-floor shower head drain underneath the flooring of the third-floor shower room out into hallway tile floor. Observation on 5/1/19 at 2:00 PM, revealed tile in the hallway was black and gray in color outside of the third-floor shower room. A green color mat was in front of the shower door. When you opened the shower door the threshold had a towel laying in the threshold in which it was soaked with water. When you enter the shower room the flooring had water seeping out from under the flooring. An interview with the DES #97 was conducted on 5/1/19 at 3:45 PM, stated when you turn the shower head on the drain leaks water under the flooring of the shower room and continues underneath the tile in the hallway. The DES #97 said he only had knowledge of the floor leaking water underneath the flooring in the shower room and under the tile floor in the hallway for about two (2) weeks. The DES #97 said someone from (company name) is to come and fix the flooring within 30 days. The DES #97 revealed the housekeepers change the green mats around 7:00 AM, and then again about 11:00 PM, every day. The DES #97 confirmed the nursing staff continued giving residents showers in the third-floor shower room. The DES #97 showed surveyor the housekeepers had changed the mats about an hour ago. The green mat hung over the shower room toilet. This toilet is used by the residents. The observation and feeling of the green mat revealed the mat was completely soaking wet and the DES #97 pointed at the towel which was at the threshold of the shower room and the hallway. The towel was soaked with water and very wet seeping out in the hallway across the threshold. The facility staff had one (1) yellow caution wet floor sign past the leaking water under the tile floor in the hallway. The DES #97 was asked whether he could stop all water to the main shower room on the third- floor and he said the staff told him that would make them take their resident down stairs on the elevator to get a shower. He said this is a dignity issue. DES #97 said the nursing staff is having to walk and pull the resident shower Bed, and wheelchair over the wet tile floor, green mat, and the towel. The DES #97 was asked is this not dangerous and the DES #97 stated, Yes it is. The DES #97 said he was told it might be 30 days. During this time frame, the facility had knowledge of this issue and still had not corrected the problem. This procedure has the potential for residents, facility staff and the public who visit that area could slip and fall resulting in a serious injury. The wet flooring is a safety hazard the wet floor sign is not located in an area adjacent to the slippery floor area. This created a potential for individuals (residents, facility staff, and the public) to slip and fall resulting in a serious outcome. The clinical quality specialist #155 on 05/01/19 at 5:55 PM, was informed of the water leaking from the shower head in the shower room going underneath the floor and out into the hallway on the third-floor shower room. On 05/02/19 at 8:30 AM, the Administrator of the facility confirmed that she knew about the third-floor shower room leaking water from the drain under the floor in the shower room, and out under the tile floor in the hallway for about three (3) weeks. The Administrator said she had called (company's name ) and they are to come and replace the flooring. The Administrator was asked for the information she had related to (, the repair of the floor of the third-floor shower room and hallway. The Administrator at the time of exiting the facility did not provide any information related to (company's name) coming to fix the third-floor shower room flooring and hallway tile floor. On 05/02/19 at 11:00 AM, observed a yellow caution wet floor sign in front and behind the leaking water under the hallway floor tile. There was a notice on the shower door that said Shower out of use this AM. Yellow and black tape caution criss-cross on the third-floor shower door that said caution wet floor. There were two notices near the third-floor shower hall that said, sorry in red letters, temporary closed. There was another sign saying notice in blue lettering, temporary out of service. In an interview on 05/02/19 at 11:15 AM, with the Assistant Director of Nursing (ADON) #122, said they took the shower out of use this AM. The ADON stated that, We are going to use the second-floor shower. 2) body wash and shampoo wash accessible to residents in the unlocked third-floor shower room. Observation of the unlocked third-floor shower room on 05/01/19 at 5:20 PM, one (1) bottle of provon shampoo and body wash was open. The bottle container had the content of Stay away from children, if swallowed you must contact the poison control center. A wet green mat laying over the toilet. In an interview on 05/01/19 at 5:30 PM, with the ADON #22, she acknowledges all the above infection control issues in the third-floor shower room. A review of the safety data sheet for the Provon tearless shampoo and body wash hazard identification: causes serious eye irritation. c) Resident #136 During an interview on 04/29/19 at 11:27 AM, with Resident #136, it was noted that the trapeze over his head was not on chains, but instead the triangle bar used to pull up on was by sitting on the top of the support haphazardly and had the potential to fall on his head. During an interview on 04/30/19 at 12:00 PM, Registered Nurse-Unit Manager was witness to the trapeze over his head and the chains were still not connected. She agreed it could hit him if it fell , because it was just setting above his head and not hooked to anything. During a brief interview on 04/30/19 at 3:39 PM, Director of Physical Therapy (DPT) #111 stated, that they removed the trapeze on 10/29/ (YEAR) and again at the end of (MONTH) and into January, but he requested it to be put back up. During an interview on 05/01/19 at 4:00 PM, DPT #111 stated that they removed the trapeze again and will work with him to get the appropriate appliance for him. During an interview on 05/02/19 at 10:30 AM, Administrator said that she went the room of Resident #136 and saw the trapeze bar herself them to remove it right away.",2020-09-01
682,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,690,D,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, medical record review, staff interview and facility policy review, the facility failed to ensure appropriate catheter care based on current professional standards of practice. This was true for three (3) of Three (3) residents reviewed in the care area of catheter care. Identified Residents #93, #80, and #153. Facility census 155. Findings included: Facility Policy titled, Nephrostomy Tube Care Dated 01/02/14 -Tape tubing to prevent tension on tube and assure tube is not kinked. -Plus, it contains the steps to cleansing the wound and dressing change. -Keep nephrostomy tube below the level of the bladder Facility Policy titled, Ostomy Care. Dated: 01/02/19 The Facility did not provide a policy of the care of a Supra-pubic Catheter a) Resident #93 During an interview on 04/29/19 at 1:59 PM, Resident # 93 was asked where were her nephrostomy tubes and the collection drainage bags. Resident #93 pulled her shirt up and pulled the folded drainage bags out of the wraste band of her pants. She was asked if she always keeps the foley bags there and she said, well yes most of the time or I set on them so they don't fall in the floor. During an interview on 04/30/19 at 4:00 PM, registered Nurse-Unit Manager #88 was asked if the staff has been trained on the care of nephrostomy foley bags. She answered yes. She was asked if we could interview a Nurse Aide that provides care for Resident #93. During an interview on 04/30/19 at 4:12 PM, Nurse Aide #21 was asked if she knows where Resident # 93 keeps her foley bags. She said if she is in bed they are beside of her or under her. If she is in her wheel chair they are behind her, sometimes she holds them like a baby and sometimes she has them under her clothes. She said, that she had not seem them in the wraste of her pants. During an interview on 04/30/19 at 4:18 PM, RN-UM#88 said that she is not sure if the NA's know how to position or the care of that type of foley, but she will educate them. During an interview on 05/01/19 at 10:11 AM, RN-UM #88 verified that Resident #93 had her Nephrostomy foley bags folded and in the wraste of her pants, urine was leaking from them. The tubes had sediment in them. Resident # 93 said that she has to squeeze that slimy stuff out of them. RN-UM#88 not to do that and she would tell the nurse to flush them the resident did not know what flush the tubes meant, it was explained to her and said no one has ever done that . Physicain orders copied from the elctronic chart pretaining to the care of the nephrostomy tubes: Flush bilateral nephro tubes with 10 mL NSS every shift. every day shift related to DISPLACEMENT OF NEPHROSTOMY CATHETER, INITIAL ENCOUNTER Verbal Active 04/24/2019 During an observation on 05/01/19 at 4:01 PM, Licensed Practical Nurse (LPN) #13 change the dressing on the nephrostomy tubes. RN-UM #88 asked to observe as well and agreed to not prompt or instruct LPN #13 on what to do. LPN #13 removed the dressing and she opened the package that had steriol gloves and barrier cloth inside the prepackaged kit. LPN #13 stood and looked at the supplies of a few minutes, before the RN-UM #88 said just think about it what do you need to do first. LPN #13 shock her head no. She had to have step by step instruction to preform the wound dressing change. On 05/01/19 at 4:20 PM, LPN #13 was asked if she could do that care without being given instructions. She answerd yes. RN-UM #88 agreed that LPN #13 needed some training and over site, before she would be compentent in wound care. b) Resident #80 During an interview on 04/29/19 at 12:05 PM, with Resident #80 it was noticed that there was not an anchor (a sercure device used to prevent tissue damage and/or accidental removal. On 04/29/19 at 12:24 PM, Nurse Aide (NA) #23 was witness to see no anchor was on catheter. On 04/29/19 at 12:29 PM, Registered Nurse-Unit Manager (RNUM) #88 stated that Resident # 80 does not wear a leg strap because she is an above the knee [MEDICAL CONDITION] and that the foley kits do not come with a anchor device and the legs straps do not work on her. She also asked if she still should have an anchor if she had a supra-pubic catheter. She was asked if she had tried a different type and she stated that she was unaware of anything different, but she will check with central supply for something other then a leg strap. She was asked for a policy for supra-pubic catheter care. One was not provided. On the web site,Nursing best Practicies for Supra Pubic Catheter Care contained the following statement: -Care of - Dressing will be changed daily & prn - Established sites (after 5 - 7 days) without drainage may not require a dressing - All suprapubic catheters must be secured to the abdomen with an appropriate anchoring device (i.e. [MEDICATION NAME] Universal securement device). c) Resident # 153 During initial tour of the facility on 04/29/19 at 11:55 AM Resident #153's nephrostomy bags were lying one on each side of the resident above the level of the kidneys. Again on 04/29/19 at 3:15 PM the nephrostomy bags remained in the same position. On 04/30/19 at 8:30 AM the nephrostomy bags were above the level of the kidneys. At this time nursing assistant (NA) #29 expressed this is the position the bags are always in. Again on this date at at 12:50 PM the nephrostomy bags were in the same position. Review of the facility's nephrostomy tube care with a revision date of 01/02/14, section 24.1 reveals, to keep nephrostomy tube below the level of the bladder. On 04/30/19 at 4:00 PM registered nurse #88 agreed the nephrostomy bags should be below the level of the kidneys.",2020-09-01
683,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,695,D,0,1,33QL11,"Based on observation staff interview and medical record review the facility failed to ensure professional standards of practice in relation to the oxygen rate while using an Oxymizer Pendant (Oxygen tubing that when used you should use a lesser setting or flow rate of oxygen), and orders for the flow rate when the device was in use. Resident # 36. This was true for 1 of 1 reviewed in the care area of respiratory care. Identified Resident #36. Facility census 155. Findings Included: During an observation and interview on 04/29/19 at 1:39 PM, Resident #36 was asked what her Oxygen flow rate was supposed to be. She said at two (2) liters when I use the regular tubing, but one point five (1.5) when I am wearing this one on the portable tank. She was pointing to the tubing with a clear pendant (Oxymizer). The portable tank was set at 1.5 liters. During an interview on 05/01/19 at 4:00 PM, Registered Nurse-Unit Manager (RN-UM) #88 was asked for information about the Oxymizer. During an interview on 05/02/19 at 9:00 AM, RN-UM #88 provided a package insert that came with the oxygen tubing Oxymizer. She was asked if there was another order for a flow rate when using the Oxymizer. She stated, that there was not, but she would get one. On 05/02/19 at 9:45 AM, RN-UM #88 provided an order dated 05/02/19 at 9:35 AM, When resident is up in wheel chair and using Oxymizer Conserving Device, Oxygen rate is to be 1/2 the amount prescribed of two liters/minute. Per Family Nurse Practitioner #158. There was no order for the flow rate until surveyor intervention.",2020-09-01
684,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,725,E,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, resident council member interviews, review of grievance reports, review of [MEDICATION NAME], and staff interviews, the facility failed to ensure it deployed nursing staff to answer call lights in a timely manner. This had the potential to affect more than a limited number of residents. Resident identifiers: #101, #110, #89, #123, #116, #96, #36, #31, #65, #10, #86, #136, #80. Facility census: 155. Findings include: a) Resident #101 During an interview with Resident #101 on 04/30/19 08:50 AM, she said sometimes it takes two (2) hours for staff to answer her call light. She said this is a pretty regular event. She said there is no particular shift or day of the week when this occurs. She said They ignore it (call light). She said she has complained about it, but it does no good. She declined to identify to whom she had voiced complaints. She said she will be discharged to home soon, and she does not want to cause trouble. The medical record was reviewed on 05/01/19 at 2:00 PM. Review of the most recent brief interviews for mental status (BIMS) found that on 04/19/19 her score was eleven (11). On 04/25/19 her BIMS score was ten (10). A score of nine (9) to ten (10) indicates moderate cognitive impairment, while a score of thirteen (13) to fifteen (15) indicates intact cognitive functioning. Review of the quarterly minimum data set (MDS) with assessment reference date (ARD) 03/29/19, assessed her BIMS score at thirteen (13). An interview was conducted with nurse aide #12 (NA #12) on 05/01/19 at 5:15 PM. She said that a couple of weeks ago there was an incident where her call light was not lighting up. She said she assumed the problem was corrected because the light has since been working. She said today the call light was not lighting up at the door, although it lit up at the nurse's station. She said she heard they fixed it again. She said she answered the resident's call light yesterday and it lit up at the doorway. She had no explanation as to why the problem occurred two (2) weeks apart. She denied knowing of problems with any other call lights on this unit. During an interview with the director of nursing (DON) on 05/02/19 at 9:00 AM, Resident #101's comment was shared. b) Resident Council meeting Resident: #110, #89, #123, #116, #96, #36, #31, #65, #10, and #86 attended Resident Council meeting on 04/30/19 at 10:00 AM. The brief interview for mental status (BIMS) for these residents include; one (1) with a BIMS indicating intact cognition, four (4) with BIMS indicating moderately impaired cognition, and three (3) with a BIMS indicating severely impaired cognition. Concerns related to staff deployment include; warm food served on the units is to cold, cold food served on the unit is too warm, call bell response is slow and sometimes the wait causes a resident to sit in a soiled brief for extended period of times (up to forty-five (45) minutes, failure to offer bedtime snacks to all, and failure to take residents who need assistance outside.",2020-09-01
685,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,726,F,0,1,33QL11,"**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 nursing staff had 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. The facility failed to ensure residents were free from abuse and neglect and failed to report alleged violations of abuse and neglect. The facility also failed to ensure contracture care was provided to dependent residents, to provide treatment and services to prevent and heal pressure ulcers, and to provide catheter care in accordance with professional standards of treatment. The facility also failed to establish a system to record receipt and disposition of all controlled drugs. Additionally, 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. These failed practices had the potential to affect all residents in the facility. Facility census: 155. Findings included: a) F600 1. Resident # 36 During an interview on 4/29/19 at 1:24 PM, Resident #36 said, that three (3) staff members that are not allowed in her room anymore. Nurse Aide (NA) #139 was rude to her when her [MEDICATION NAME] (at surgical created stoma to drain urine from the bladder) bag busted opened. She said, that she was covered in urine. This was witnessed by a Licensed Practical Nurse (LPN) #73. She said, that the LPN came back in her room to take her statement, because she said that this incident had to be reported. She also stated that the Social Worker (SW) came to talk to her. She also stated that Licensed Practical Nurse (LPN) #16 refused to change [MEDICATION NAME] bag. It had leaked urine all over her. She said LPN #88 was always rude and snappy when she would ask her a question. She stated that she dreads it when she knows LPN #16 is going to work. She also stated that she had witnessed this same LPN #16 yell at another resident that does not know what she is doing at times. Looking for the reportable that was supposed to done on NA#139 could not be found. During a brief interview on 05/01/19 at 12:30 PM, with Registered Nurse-Unit Manager Director (RN-UM) #88, was asked if she could recall this event and if it was reported. She said yes, she gave the information to the Social (SW) #13 after the morning meeting. She was asked she filled out the, Adult Protective Services Mandatory Reporting Form. She replied no that she does not do that, she writes on a plain sheet of paper and that the SW fills those out. It this time she was also informed of the complaint about on LPN#16. During an interview on 05/01/19 at 1:45 PM, SW #13 was asked if she had completed the form for the reportable? She stated, that if she was handed any information about that she would have filled out the form and interviewed the resident. She stated that she will look again. She also informed about the complaint about LPN# 16. During a brief interview on 05/01/19 at 1:55 PM, with SW #13 stated that she cannot find where a report was done and maybe RN-UM #88 may not have given her the information. During a meeting on 05/01/19 at 2:00 PM, RN-UM #88 stated, that she remembers giving her SW # 13, the paper with the complaint on it. She was asked if she had made a copy for herself, and she replied no she did not. During a revisit on 05/01/19 at 3:25 PM, with Resident #36, SW #13 was in her room talking to her about both complaints one on NA#136 and LPN#16. 2. Resident #86 During an interview on 04/30/19 at 3:09 PM, Resident # 86 said, that Rehab Tech #58 hop changed her Wheel Chair (W/C) out for a different one and it is hard for her to get herself on and off of the toilet. She stated that LPN# 16 is hateful, rude, mean and likes to quarrel about having to help her out of the W/C to use the bathroom. She said, that she tells her that she can do it herself if she wanted to and that she is just being lazy. Resident #86 stated, that she feels like she has lost her rights. Resident # 86 stated she did not tell anyone because she is at the mercy of LPN #16 and she was afraid for her life because she does not know what she would do to get back at her. During an interview on 04/30/19 at 3:24 PM, RN-UM #88 was informed of allegation of LPN#16 being rude to Resident #86 and why she did not tell anyone about it. RN-UM#88 said she was not aware of any of this. She said she knows LPN #16 does not smile but she just assumed it was just her personality. She said that this nurse would be here tomorrow if I would want to talk to her. On 05/01/19 at 4:30 PM, SW #124 informed this Surveyor that a report is being done as we speak concerning NA#136 and LPN #16. She went on to say that NA# 136 will be told not to return to work until after the investigation has been completed. She stated, the LPN# 16 is being asked to leave now until after the investigation is also completed. Also a reoportable and investigation for Resident #86. She stated that they are going to interview all residents that had received care from LPN #16. During an interview on 05/02/19 at 10:00 AM, Administrator states, that she had not rested all night thinking about Resident #36 and the NA #136 and LPN #16. She said, that has had to write both of these people up for being rude and confrontational with co-workers. She went on to say that she knows that there has been two (2) major incidents with LPN #16 but can only find one write-up. She said that she should have known if LPN#16 is rude to her co-worker then she could be rude to the Residents and that is upsetting to her. She also states that NA #136 has also been written-up for bullying, gossiping, and making verbal threats towards her peers. She was counseled on 11/07/18 and 11/21/18 the final counseling was on 11/28/18 for continuing to bully, gossip and making verbal threats. On 05/02/19 at 10:30 AM, Social Worker # 124 provided three (3) reportable completed on 05/01/19. Two (2) were from Resident #36 about NA #136 and LPN #16. One (1) was from Resident #86 about LPN #16. b) 609 1. Resident #36 Facility policy titled, OPS300 Abuse Prohibition Revision Date: 07/01/18; - Identification of possible incidents and allegation which need investigation -Investigation of incidents and allegations -Reporting of incidents, investigations, and Center response to the results of their investigations. -Initiate an investigation within 24 hours if the event does not result in serious bodily injury. During an interview on 4/29/19 at 1:24 PM, Resident #36 said, that three (3) staff members that are not allowed in her room anymore. Nurse Aide (NA) #139 was rude to her when her [MEDICATION NAME] (at surgical created stoma to drain urine from the bladder) bag busted opened. She said, that she was covered in urine. This was witnessed by a Licensed Practical Nurse (LPN) #73. She said, that the LPN came back in her room to take her statement, because she said that this incident had to be reported. She also stated that the Social Worker (SW) came to talk to her. She also stated that Licensed Practical Nurse #16 (LPN) refused to change [MEDICATION NAME] bag. It had leaked urine all over her. She said LPN #88 was always rude and snappy when she would ask her a question. She stated that she dreads it when she knows LPN #16 is going to work. She also stated that she had witnessed this same LPN #88 yell at another resident that does not know what she is doing at times. Looking for the reportable that was supposed to done on NA#139 could not be found. During a brief interview on 05/01/19 at 12:30 PM, with Registered Nurse-Unit Manager Director (RN-UM) #88, was asked if she could recall this event and if it was reported. She said yes, she gave the information to the Social (SW) #13 after the morning meeting. She was asked she filled out the, Adult Protective Services Mandatory Reporting Form. She replied no that she does not do that, she writes on a plain sheet of paper and that the SW files those out. It this time she was also informed of the complaint about on LPN#16. During an interview on 05/01/19 at 1:45 PM, SW #13 was asked if she had completed the form for the reportable? She stated, that if she was handed any information about that she would have filled out the form and interviewed the resident. She stated that she will look again. She also informed about the complaint about LPN# 16. During a brief interview on 05/01/19 at 1:55 PM, with SW #13 stated that she cannot find where a report was done and maybe RN-UM #88 may not have given her the information. During a meeting on 05/01/19 at 2:00 PM, RN-UM #88 stated, that she remembers giving her SW # 13, the paper with the complaint on it. She was asked if she had made a copy for herself, and she replied no she did not. During a revisit on 05/01/19 at 3:25 PM, with Resident #36, SW #13 was in her room talking to her about both complaints one on NA#136 and LPN#16. c) 677 1. Resident #19 On 04/30/19 at 8:30 AM a request was made for registered nurse (RN) #88 to open the contractured left hand of Resident #19. While opening the hand there was a strong odor, the palm had an indentation from the nail on the ring finger, and the nail needed to be trimmed. Resident nurse #88 agreed the left hand needed cleaned and the nail cut. She completed both within a few minutes. d) 684 1. Resident #89 During an observation on 05/01/19 at 10:38 AM, Licensed Practical Nurse (LPN) #64 had pre-pulled the medications for Resident # 89 in the top draw of the medication cart he was using that day. He was asked about these cups of medications. He stated, that the resident was not in their room and that is why the cups of medications were in his cart. He was asked what he was going to do with the medication that he had pre-pulled. He stated that he was going to discard them. He was then asked if he was going to waste them than why had he took the time to write the room number and bed letter on each cup of medication. He said, well I guess you got me on that one 2. Resident #30 During an observation on 05/01/19 at 10:38 AM, Licensed Practical Nurse (LPN) #64 had pre-pulled the medications for Resident # 30 in the top draw of the medication cart he was using that day. He was asked about these cups of medications. He stated, that the resident was not in their room and that is why the cups of medications were in his cart. He was asked what he was going to do with the medication that he had pre-pulled. He stated that he was going to discard them. He was then asked if he was going to waste them than why had he took the time to write the room number and bed letter on each cup of medication. He said, well I guess you got me on that one 3. Resident #10 During an observation on 05/01/19 at 10:38 AM, Licensed Practical Nurse (LPN) #64 had pre-pulled the medications for Resident # 10 in the top draw of the medication cart he was using that day. He was asked about these cups of medications. He stated, that the resident was not in their room and that is why the cups of medications were in his cart. He was asked what he was going to do with the medication that he had pre-pulled. He stated that he was going to discard them. He was then asked if he was going to waste them than why had he took the time to write the room number and bed letter on each cup of medication. He said, well I guess you got me on that one 4. Resident #77 During an observation on 05/01/19 at 10:38 AM, Licensed Practical Nurse (LPN) #64 had pre-pulled the medications for Resident # 77 in the top draw of the medication cart he was using that day. He was asked about these cups of medications. He stated, that the resident was not in their room and that is why the cups of medications were in his cart. He was asked what he was going to do with the medication that he had pre-pulled. He stated that he was going to discard them. He was then asked if he was going to waste them than why had he took the time to write the room number and bed letter on each cup of medication. He said, well I guess you got me on that one 5. Resident #84 During an observation on 05/01/19 at 10:38 AM, Licensed Practical Nurse (LPN) #64 had pre-pulled the medications for Resident # 84 in the top draw of the medication cart he was using that day. He was asked about these cups of medications. He stated, that the resident was not in their room and that is why the cups of medications were in his cart. He was asked what he was going to do with the medication that he had pre-pulled. He stated that he was going to discard them. He was then asked if he was going to waste them than why had he took the time to write the room number and bed letter on each cup of medication. He said, well I guess you got me on that one 6. Resident #128 During an observation on 05/01/19 at 10:38 AM, Licensed Practical Nurse (LPN) #64 had pre-pulled the medications for Resident # 128 in the top draw of the medication cart he was using that day. He was asked about these cups of medications. He stated, that the resident was not in their room and that is why the cups of medications were in his cart. He was asked what he was going to do with the medication that he had pre-pulled. He stated that he was going to discard them. He was then asked if he was going to waste them than why had he took the time to write the room number and bed letter on each cup of medication. He said, well I guess you got me on that one 7. Resident #66 During an observation on 05/01/19 at 10:38 AM, Licensed Practical Nurse (LPN) #64 had pre-pulled the medications for Resident # 66 in the top draw of the medication cart he was using that day. He was asked about these cups of medications. He stated, that the resident was not in their room and that is why the cups of medications were in his cart. He was asked what he was going to do with the medication that he had pre-pulled. He stated that he was going to discard them. He was then asked if he was going to waste them than why had he took the time to write the room number and bed letter on each cup of medication. He said, well I guess you got me on that one 8. Resident #140 The facility failed to follow physician's orders for nebulizer administration. The physician ordered albuteral nebulizer treatments every four (4) hours. The order was transcribed incorrectly on 04/23/19 instead to every four (4) hours as needed. From 04/23/19 through 04/30/19 she received only three (3) albuteral neb treatments as follows: 04/23/19 at 2045; 04/24/19 at 10 AM; 04/26/19 at 8:40 AM. The medical record was reviewed on 05/01/19. Resident #140 has [MEDICAL CONDITIONS]. Prior to a (MONTH) 2019 hospitalization , she had physician orders for [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) nebulizer treatments every four (4) hours for dyspnea, wheezing, and cough. Review of the medication administration record(MAR) for early (MONTH) pre-hospitalization dates found she took it around the clock with few exceptions. Review of the hospital discharge summary dated 03/28/19 found that the hospital recommended that she continue the same nebulizer treatments upon return to the nursing home. Review of the facility's physician order sheet and interim plan of care dated 03/28/19 contained orders for Albuteral nebulization treatments every four (4) hours for shortness of breath. The facility physician signed those orders on 03/29/19. Review of the March, 2019 MAR found an order for [REDACTED]. Review of the (MONTH) 2019 MAR found she continued to receive albuteral nebulization treatments every four (4) hours which she consistently accepted. Further review of the (MONTH) 2019 MAR found that the facility changed over to electronic health records (EHR) on 04/23/19 in the evening. The EHR MAR indicated [REDACTED]. Review of the (MONTH) MAR from 04/24/19 through 04/30/19 found she received only two (2) albuteral nebulization treatments. One occurred at 10 AM on 04/24/19, and the other occurred on 04/26/19 at 8:40 AM. An interview was conducted with the corporate quality services registered nurse #155 (CQS #155) and the director of nursing (DON) on 05/01/19 at 2:30 PM. It was discussed that on 03/28/19 instead of the [MEDICATION NAME] ([MEDICATION NAME]-albuteral), the nurse who reconciled the orders instead wrote only albuteral nebulization treatments. According to the manufacturer's guidelines, this delivered .5 milligrams less Albuteral than did the [MEDICATION NAME]. The CQS and DON said the physician signed the re-admission orders [REDACTED]. The CQS said that a transcription error must have occurred when the facility switched to EHR on 04/23/19, which led to the resident receiving the Albuteral nebulization treatments only every four (4) hours prn (as needed) rather than every four (4) hours around the clock as the physician ordered. An interview was conducted with the CQS and nurse practitioner #158 (NP #158) on 05/01/19 at 2:45 PM. They said there were no physician orders to discontinue the Albuteral nebulization treatments ordered every four (4) hours. They said there were no new physician orders to administer Albuteral nebulization treatments every four (4) hours prn. The CQS agreed that the facility failed to follow physician orders for the Albuteral nebulizer treatments every four (4) hours following the 04/23/19 change over to EHR system. NP #158 said she will assess the resident today, and see if the resident is able and agreeable with keeping the nebulization treatments every four (4) hours prn. 9. Resident #130 Observation on 04/29/19 at 3:57 PM revealed Resident #130 with bilateral contractures of the hands with no devices in place. Review of the medical record revealed he has palm protectors ordered. Observation on 05/01/19 at 5:00 PM found a folded washcloth in his right hand. He used a communication board to say they keep a supply of washcloths in his bedside stand. During an interview with his nurse aide #14 (NA #14) at this time, she said they use a washcloth in the right hand only. She said she thought this was because the index finger on his right hand was bent downward and inward, and they were trying to protect the skin integrity of his palm. Review of the medical record on 05/01/19 at 5:30 PM found current physician orders as follows: {typed as written} Palm Protectors With Finger Separators to Right Hand. Wear As Tolerated. Remove For Hygiene. every day and night shift. Review of the care plan on 05/01/19 at 5:30 PM revealed an intervention initiated 04/15/19 as follows: {Typed as written} Palm Protectors With Finger Separators to Right Hand. Wear As Tolerated. Remove For Hygiene. An interview was conducted with licensed nurse #140 (LPN #140) on 05/01/19 at 5:43 PM. She said they use a washcloth in his right hand, not a palm guard with finger separators. She said he has no wounds of any type at this point in time. An interview was conducted with occupational therapy employee #152 (COTA #152) on 05/02/19 at 8:00 AM. She said they (therapy) recommended he use a palm protector with finger separators if tolerated. If not tolerated, she said that he can use washcloths. She was informed that he was care planned for the palm protector with finger separators to the right hand, not the wash cloth, yet staff were using only a washcloth. Relayed that nothing is used in the left hand. She said she would speak with the therapy director about this, who in turn will be in contact with nursing. An interview with the assistant director of nursing (ADON) and the corporate quality services registered nurse #155 (CQS #155) on 05/02/19 at 12:45 PM found that a new order from the physician was entered into the electronic medical record (EHR) this morning for a washcloth to the right hand. The ADON said she revised the care plan today to reflect that change. At approximately 1:00 PM on 05/02/19 the director of nursing (DON) provided a copy of a verbal physician order dated 05/01/19 at 10:49 PM which stated the following: {typed as written} Resident To Have Wash Cloth in right Hand as tolerated. (MONTH) Remove For Skin Checks & (symbol for and) Hygiene. The start date for this order was the 7 a - 3 p shift on 05/02/19. 10. Resident #44 The medical record was reviewed on 04/30/19. Review of the recapitulation of physician's orders for (MONTH) and (MONTH) 2019 found physician orders to administer [MEDICATION NAME] Insulin ten (10) units subcutaneously with meals related to diabetes mellitus. It included directives to withhold the insulin if the blood sugar was less than 150 milligrams/deciliter (mg/dl). Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Per physician's orders, the insulin should have been withheld. However, the nurse administered ten (10) units of [MEDICATION NAME] insulin. Also, at 7:30 AM on 04/24/19 and on 04/25/19 the space in which to document the blood sugar results and the administration of insulin was left blank. During an interview with the director of nursing (DON) on 04/30/19 at 3:00 PM, it was discussed that the resident received ten (10) units of [MEDICATION NAME]on 04/26/19 at 7:30 AM when the blood sugar was only 106 mg/dl. She agreed that the insulin should have been withheld. It was also discussed that at 7:30 AM on 04/24/19 and on 04/25/19 there was no evidence as to the blood sugar result and/or if the insulin was given or was held. The DON agreed and offered no further explanation. An interview was conducted with the administrator on 05/01/19 at 9:45 AM. She was informed that on 04/26/19 at 7:30 AM this resident received insulin when she had a blood sugar reading of 106 mg/dl. It was discussed that the physician set a parameter directing to not give the insulin with meals when the blood sugar was less than 150 mg/dl. It was also discussed that there was no evidence on 04/24/19 and 04/25/19 at 7:30 AM if the nurse followed the physician's order to assess the blood sugar at that time and administer insulin. No further information was provided prior to exit. 11. Resident #4 In an interview on 04/30/19 at 4:18 PM, Resident #4 said she has sores on both legs, the fluid builds up, and drain out of her legs. Resident #4 said her treatment is to have her legs wrapped. Resident #4 scored a 12 on her Brief Interview for Mental Status (BIMS)on a significant change of status. 01/23/19. A score of 8-12 indicates moderately impaired cognitively. Under section B, the Resident makes self-understood is coded as understood, and the resident's ability to understand others is coded as understands clear comprehension. On 04/30/19 at 2:53 PM, Licensed Practical Nurse (LPN) #6 said the resident is taking a diuretic medication ([MEDICATION NAME] and [MEDICATION NAME])( a diuretic increase urine production in the kidneys, promoting the removal of salt and fluid from the body). LPN #6 revealed that Resident #4 has an order to have her legs wrapped every week, but the resident refuses to have her legs wrapped in the summer due to it is too hot. The LPN thought the Physical Therapy was wrapping Resident #4's legs. Observation of Resident #4's bilateral legs with LPN #6 on 04/30/19 at 3:07 PM, found the resident's legs were not wrapped. Resident's #4's legs were [MEDICAL CONDITION] and had a flaky loose scale. The LPN #6 picked up resident #4's right leg and the observation revealed an open [MEDICAL CONDITION] on the back of her leg, and knee which both were red, and weeping clear fluid. There was a brown crusty scab around the open areas. The left lower leg was excoriated red, with a hard, rough, brown scab of dried blood. There was multiple open lesion on her left leg. Observed a sheet underneath Resident #4's legs which had dried brown/burgundy stains on the sheet. LPN #6 was asked why Resident #4's legs not wrapped. LPN #6 did not make a comment. A review of Resident #4's physician order dated 03/13/19. The physician order states to cleanse venous ulcer to left lateral leg with wound cleanser pat dry, apply Optilock and wrap with fourflex wraps every seven (7) days and whenever needed (PRN). The physician order for [REDACTED]. A review of Resident #4's nursing notes on 04/30/19 at 3:11 PM, found LPN #6 had documented Resident #4 had refused to have treatment to her left leg wounds on 04/24/19. A review of Treatment Administration Sheet (TAR) found no one signed off for the treatment to Resident #4's left leg wound on 04/17/19. The LPN #6 wrote refused on the TAR for 04/24/19. The record finds the Nurse Practitioner (NP) and/or the physician was not notified of Resident #4 refusing her treatment to her left leg on 04/24/19 or why the staff did not follow the physician order to treat Resident #4's left leg on 04/17/19. A review of the TAR for the right leg wound treatment found no signatures on 04/18/19 and 04/25/19. There were no notification to the NP and/or physician of why the treatment was not performed as ordered. When LPN #6 was asked why she did not follow the physician order for [REDACTED].#6 stated that, Nurse Practitioner (NP) #157 was on duty that day. LPN #6 confirmed that she did not notify the NP that Resident #4 refused her treatment on 04/24/19. The LPN stated she did not know why Resident #4 did not receive her wound treatment to her left leg on 04/17/19. LPN #6 also acknowledge Resident #4 did not receive treatment to her right leg on 04/18/19 and 04/25/19. In an interview with NP# 157 on 04/30/19 at 3:15 PM, the NP was asked whether the staff informed her Resident #4 had refused her treatment to her left leg, or the staff was not following the physician order to treat Resident #4's right or left leg at any time in (MONTH) 2019, the NP stated that, the staff did not notify her of the wound treatment not being done for Resident #4's right and left leg for the month of (MONTH) 2019. The Center Nurse Executive (CNE) #22 confirmed the treatment to Resident #4 was not performed by her staff as the physician ordered for the left leg on 04/17/19 and 4/24/19. The CNE agreed that Resident #4's right leg treatment was also not performed on 04/18/19 and 04/25/19. The CNE agreed that her staff did not notify a physician nor an NP of the resident's refusal to have her treatment to her left leg and/or why they did not follow the physician order to performed Resident #4's treatment to her right and left leg for the above dates. 12. Resident #116 During Resident Council meeting on 04/30/19 at 10:00 AM Resident #116, whom has an intact cognitive ability, expressed a concern with staff answering call bells timely. At times there is a forty-five (45) minute wait after pressing the call bell before staff responds to assist in changing a soiled brief. Nine other residents at the meeting agreed call bells are often not answered in a timely manner. 13. Resident #108 Resident #108 had an order written [REDACTED]. Ten (10) days of antibiotics twice a day meant Resident #108 should have received 20 doses of [MEDICATION NAME]. Review of Resident #108's Medication Administration Record [REDACTED]. During an interview on 05/01/19 at 5:58 PM, the Unit Director and the Facility Director of Nursing confirmed Resident #108's MAR indicated [REDACTED]. No further information was provided through the completion of the survey. 14. Resident #154 Resident #154 was admitted to the facility 04/11/19. Resident #154 received total [MEDICATION NAME] nutrition (TPN) therapy, a method of infusing fluids into a vein to bypass the gastrointestinal tract and provide nutrients needed. Resident #154 had the following orders: - Weigh every day shift, every Thursday, written on 04/11/19, to start 04/18/19 - Weigh one time a day, every 7 day(s) for monitor for 4 weeks until finished, written on 04/23/19, to start 04/23/19, to end 05/21/19 Review of Resident #154's medical records revealed the only weight recorded for the resident was an admission weight on 04/11/19. During an interview on 05/01/19 at 11:42 AM, Corporate Quality Services Registered Nurse verified Resident #154's weight had not been recorded since admission. She stated Resident #154's weight would be obtained immediately. Resident #154 also had an order for [REDACTED]. Review of Resident #154's medical records revealed no laboratory testing performed on 04/15/19. Laboratory testing consisting of a complete blood count and comprehensive metabolic panel was performed on 04/16/19. During an interview on 05/01/19 at 3:15 PM, the Director of Nursing confirmed Resident #154 did not have laboratory testing on 04/15/19. She stated Resident #154 did have laboratory testing performed on 04/16/19 but confirmed this laboratory testing did not include a magnesium level and phosphorus level as ordered by the physician to be performed weekly. No further information was provided through the completion of the survey. 15. Resident #78 Resident #78 had an order written [REDACTED]. (Order typed as written.) [MEDICATION NAME] is an antipsychotic medication that can cause elevated blood glucose levels. An Accu-Check test involves the nurse obtaining a drop of blood from the resident's fingertip to check the blood glucose level. Review of Resident #78's Medication Administration Record [REDACTED]. Resident #78's progress notes did not document a blood glucose level for 05/01/19. On 05/02/19 at 11:15 AM, Licensed Practical Nurse (LPN) #200 confirmed Resident #78's monthly blood glucose monitoring was not recorded for 05/01/19. On 05/02/19 at 11:20 AM, the Unit Director confirmed Resident #78's monthly blood glucose monitoring was not recorded for 05/01/19. No further information was provided through the completion of the survey. e) F686 1. Resident #136 During an interview on 04/29/19 at 11:32 AM, Resident #136 said that he had sore on buttock. He was asked if the staff came in on a regular basis to two him every two hours. This resident was in a boating accident and suffered a stroke. He was left unable to use his legs and his left arm. He stated that the staff does not help to change his positions every two (2) hours. During an observation on 05/01/19 at 2:23 PM, Licensed Practical Nurse (LPN) # 13 provide wound care for Resident #136 no the buttock. LPN #13 appeared to be unsure of what to do she repeatedly looked to the Registered Nurse Unit Manager (RNUM) # 88 for guidance. RNUM #88 was prompting LPN#13 to wash her hands, intervening and instructing this nurse on how to provide the wound care. During an interview on 04/29/19 at 12:10 PM, RNUM #88 agreed that she had intervened and provided instruction. She also agreed that if she had not the LPN would not have pro (TRUNCATED)",2020-09-01
686,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,755,D,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, employee reords and staff interview the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and an account of all controlled drugs is maintained. This is related to not signing out a narcotic in the Narcotic book, and the failure to verify the narcotic count by two (2) nurses, and not signing out a narcotic in the Narcotic Count Book when the medication was removed for a Resident. This was a random opportunity for discovery. This had the potential to affect a limited number of residents. Facility census 155. Findings included: a) Narcotic reconciliation During an observation and interview on 05/01/19 at 9:14 AM, Licensed Practical Nurse (LPN) #16 agreed that the Narcotic Log book was incomplete on nine different days that the count sheet was not signed by two nurses, (the nurse coming on shift and the nurse ending their shift). - 04/21/19 at 7:00 AM -04/21/19 at 7:00 PM -04/22/19 at 10:00 PM -04/23/19 at 5:00 AM - 04/23/19 at 11:00 PM -04/24/19 at 6:00 AM - 04/30/19 at 7:00 AM -04/30/19 at 7:00 PM -05/01/19 at 7:00AM Copy of the count sheet page obtained. During an observation and interview on 05/01/19 at 10:13 AM, LPN # 64 agreed that the Narcotic Log book was incomplete and not done on 05/01/19 at 7:00 AM, that the count sheet was not signed by two nurses, (the nurse coming on shift and the nurse ending their shift). A random look at a narcotic count for Resident #49 revealed LPN #64 did not sign his name on the count sheet to indicate he had removed a narcotic from the card holding the medication. The count sheet revealed that there should have been 27 [MEDICATION NAME] left, but the card only had 26 pills remaining. On 05/01/19 at 10:18 AM, Registered Nurse- Unit Manager #88 was asked to witness the inaccurate narcotic count. She only stated that she was disappointed. Review of employee file revealed that LPN #16 received a, Corrective Action Notice, dated 04/10/17 and 04/11/17, for not completing a shift count of controlled substances, during an off going/on coming nurse.",2020-09-01
687,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,757,D,0,1,33QL11,"**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's drug regimen was free from unnecessary drugs. A nurse administered insulin to a resident when it was not indicated based on the blood glucose parameters. This was evident for one (1) of five (5) residents reviewed for unnecessary medications out of thirty-one (31) sampled residents. Resident identifier: #44. Facility census: 155. Findings include: a) Resident #44 The medical record was reviewed on 04/30/19. Review of the recapitulation of physician's orders [REDACTED]. It included directives to withhold the insulin if the blood sugar was less than 150 milligrams/deciliter (mg/dl). Further review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Per physician's orders [REDACTED]. However, the nurse administered ten (10) units of [MEDICATION NAME] insulin. During an interview with the director of nursing (DON) on 04/30/19 at 3:00 PM, it was discussed that the resident received ten (10) units of [MEDICATION NAME]on 04/26/19 at 7:30 AM when the blood sugar was only 106 mg/dl. She agreed that the insulin should have been withheld. An interview was conducted with the administrator on 05/01/19 at 9:45 AM. She was informed that on 04/26/19 at 7:30 AM this resident received insulin when she had a blood sugar reading of 106 mg/dl. It was discussed that the physician set a parameter directing to not given the insulin with meals when the blood sugar was less than 150 mg/dl. No further information was provided prior to exit.",2020-09-01
688,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,761,E,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure multi-use medications were labeled in accordance with currently accepted professional principles. Multi-use items did not have a date to indicate when it was initially opened, this has the potential to lose the effectiveness and/or potency if used after the recommended date after opened. Other multi-use items did not have a name or room number on the bottle as to whom it was use on or belonged to. This was a random opportunity for discovery. The facility census 155. Finding included: a) Multi-use vial During an observation on 05/01/19 at 9:14 AM, Licensed Practical Nurse (LPN) #16 agreed there was not a name, room number or an opened date on two (2) of three (3) partially used artificial tears. One (1) of six (6) vials of insulin did not have the initial date it was opened on the vial. On 05/01/19 at 10:20 AM, with LPN #64, an observation of the medication cart revealed, there was not a name, room number or initial open date on two (2) of four (4) multi-use [MEDICATION NAME] eye drops. Two (2) of eight (8) insulin pens did not have a date on which it was initially opened on the pens During an interview on 05/01/19 at 10:28 AM, Registered Nurse- Unit Manager #88 was informed of findings. She agreed that there should have been dates of when the medications where opened and an identifying room number or name on the other medication. c) Medication room During investigation of the Homestead Unit medication preparation room on 05/02/19 at 7:51 AM, a multi-dose vial of [MEDICATION NAME] purified protein derivative was noted to have an opening date of 02/17/2019. [MEDICATION NAME] purified protein derivative is given by injection to test for the [DIAGNOSES REDACTED]. Licensed Practical Nurse (LPN) #200 verified the [MEDICATION NAME] vial with date of opening 02/17/19 was past its use by date and should be discarded. The facility's Policy entitled, Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles stated, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. According to [MEDICATION NAME] prescribing information available on the Food and Drug Administration website, Vials in use for more than 30 days should be discarded. On 05/02/19 at 7:55 AM, the Unit Director was informed a multi-dose vial of [MEDICATION NAME] purified protein derivative was noted to have an opening date of 02/17/2019, which was past its use by date. No further information was provided through the completion of the survey.",2020-09-01
689,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,804,E,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of grievance/concern reports, test tray results, resident and staff interview, the facility failed to serve food that is at an appetizing temperature. Test trays conducted at lunch showed food temperatures were below the acceptable level at the point of service. Review of resident council minutes and in confidential resident council meeting held with surveyors revealed the resident had expressed concern with food temperature on several occassions. This practice has the potential to affect more than a limited number of residents who are served food from this central location. Facility census: 155 Findings include: a) 04/30/19 at 11:48 a.m. observations of lunch were conducted. It was noted that trays came to the 3rd floor at 12:55 p.m. There were at least eight (8) staff members on the unit but only one (1) was observed delivering the food to the residents at 1:15 p.m. from the room [ROOM NUMBER]. The dietary director went to the tray cart at 1:26 p.m. The resident #11 was the last tray on the cart. The lunch tray had two (2) pieces of chicken. The first piece of chiken was tempered at 114 F and the second piece was 110 F. There was additionally two (2) hot dogs on the tray. One was found to be 110 F with the second one being 109 F. Mashed potatoes were 108.9 F. The food service director was present at the time and verified the food items were not at the appropriate temperature at the point of service. Hot foods are not to be less than 120 F at the time they are served to the resident. b) Food termperatures were taken on the 2nd floor and showed the temperatures did not reach the correct temperature at the point of service as well. Temperatures were taken with the food service manager and were founed to be: tomato soup 95 F and cole slaw was placed on hot tray. The temperature was 94 F. Cold food items are to be no higher than 50 F when served to residents. c) Confidential Resident council meeting was held with the surveyor at 10:00 a.m. on 4/30/19. Ten residents were present and were all in agreement that hot foods are often served too cold and the cold foods too warm for their liking. They expressed concern that milk is poured from a pitcher and is often warm. d) Resident confidential interview held on 4/30/19 showed the resident stated if she/he eat in their room it is usually cold and the vegetables get colder the fastest. e) Review of grievance/concern files Since (MONTH) there were two greivances reported and two reports in Februay regarding food. The temperature and what alternates are available. There were reported to the dietary manager at the time for action to be taken to correct the concern. At the time of the survey, food cocnerns still existed and had not been corrected as yet. These issues were discussed with dietary manager at various times during the survey and was given opportunity to supply evidence they concens had been addressed.",2020-09-01
690,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,812,E,0,1,33QL11,"Based on observation and staff interview it was found the dietary staff has not ensured foods are handled in a manner that follows proper sanitary techniques. Staff did not wear appropriate hair covering; equipment needed cleaned, 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 foods from this central location. Facility census: 155 Findings include: a) On 04/29/19 at 11:25 p.m. the surveyor did observations in the kitchen prior to meal service. The dietary manager was present when these issues were brought to her attention: Dietary staff, a female did not have all her hair under the hairnet and a male employee with facial hair but did not have any hair restraint on. b) A cart had tires that were very dirty and heavily covered with food debris, c) the drip pan under the range top was found to be very dirty containing much food debris. It was in need of cleaning. d). Observation in the main dining room off foods being served revealed the dietary staff used the same gloved hands to handle buns for sloppy joes and then touch non-food items such as the bun wrappers, etc.",2020-09-01
691,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,842,D,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, the facility failed to ensure medical records were completed completely and accurately. One (1) resident Medication Administration Record [REDACTED]. This had the potential to affected two (2) of thirty- one ( 31) investigative residents reviewed. Resident identifiers: #87 and #154. Facility census: 155. Findings included: a) Resident #87 A review of Resident 87's physician order [REDACTED]. A review of the Medication Administration Record [REDACTED]#87 with an X, and a check mark for her Bilateral Prafo boots at all times as tolerated, may remove for skin checks and hygiene every day and night shift. The Assistant Director of Nursing (ADON) #122 was asked on 05/01/19 at 9:15 AM, what does an X mark on the 04/30/19 from 11:00 PM to 7:00 AM shift indicate for bilateral Prafo boots at all times as tolerated, may remove for skin checks and hygiene. The ADON stated that, she does not know what the X mark indicated. The Director of Nursing (DON) #22 on 05/01/19 at 11:49 AM pulled up Resident #87's Medication Administration Record [REDACTED]. The DON said you document either a yes or a no. She did not know what an X is indicating. The DON called their help desk and they told could not tell the DON what the X mark indicated The DON confirmed they needed a better system to identify whether the staff applies the boots or not, because no one could identify what the X mark indicates. b) Resident #154 Resident #154 received total [MEDICATION NAME] nutrition (TPN) therapy, a method of infusing fluids into a vein to bypass the gastrointestinal tract and provide nutrients needed. Resident #154's Medication Administration Record [REDACTED] (Orders typed as written.) - TPN 1158 ml x 12 hrs @ 130 ml/hr, [MEDICATION NAME] 235 g/799 kcals, Amino acids 90 g/360 kcals, Lipids 45 g/405 kcals, 1564 kcals/day, every 24 hours Run from 7a to 7p start at 64 ml/hr x 1 hr taper up to 130 ml/hr x 11 hrs taper down to 64 ml/hr x 1 hr. - TPN Total [MEDICATION NAME] Nutrition CYCLED 1569 ml over 12 hrs 130 ml/hr Taper up 1 hours/rate 64. Taper down 1 hours/Rate 64. Lumen to use______. In the morning for severe malnutrition. BASE SOLUTION: Electrolytes ____ ADDITIVES: Multivitamins 10 ml [MEDICATION NAME] ____ Regular insulin ____ Vitamin K _____ Famoditine ______ [MEDICATION NAME] (B1) ____ [MEDICATION NAME] (B12) ___ Folic Acid ____ Other ______. Both of the orders were initialed as given by nurses on the MAR. During an interview on 04/30/19 at 4:50 PM, the Clinical Quality Services Registered Nurse stated Resident #154's TPN should be infused at 64 ml/hour for one (1) hour, then 130 ml/hour for ten (10) hours, and then 64 ml/hour for one (1) hour. This equals 1428 total mls to be infused. The Clinical Quality Services Registered Nurse agreed Resident #154's MAR indicated [REDACTED]. She agreed the orders contained two (2) different amounts of TPN to be infused and both orders had been initialed as given by nurses. The Clinical Quality Services Registered Nurse stated she would have the order corrected. No further information was provided through the completion of the survey.",2020-09-01
692,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,867,F,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interview and facility policy review, the facility failed to identify and provide corrective actions for issues of which it should have been aware pertaining to Abuse/Neglect and the Reporting and Investigation of allegations of Abuse/Neglect. The competency of the nursing staff, failure to provide care at the current professional standards in the care areas of contracture care for dependent residents, medication pass and following physicians orders, care and treatment of [REDACTED]. This had the potential to affect all residents. Facility census 155. Findings included: During an interview on 05/02/19 at 12:37 PM, with Administrator and DoN the things that were discussed were, the allegations of abuse/neglect. They were asked about the multiple reportable and grievance/concerns about delay of care and residents waiting for extended points of time for assistance. Administrator said, that she is aware of the concerns and is currently conducting call light audits but was not interviewing residents on a regular basis to ask them if the problems were improving or not. She also said that they are as of yesterday interviewing all residents and asking about any type of abuse/neglect. She stated, that she was not aware of the lack of competencies for wound care, catheter care, infection control problems. Administrator said, they had developed a subcommittees with the Social Worker customer services. She said, that she has a lot to improve on, the Residents are her main focus. The reports of not answering call lights go back into (MONTH) to 04/24/19 from eight (8) residents with capacity and a grievance/concern form from the Resident Council meeting on 02/17/19. The only time this was addressed was in (MONTH) of 2019. Administrator states she is aware it is an ongoing problem. She stated it is hard when you are dealing with this type of culture in this area. During this interview Administrator stated that she feels like she let the residents down, because she should have known that if LPN #16 and NA #136 were rude to co-workers, then they would be rude to the residents. She went on to say, that her heart just broke when she read the statement from Resident #86 a) F600 1. Resident # 36 During an interview on 4/29/19 at 1:24 PM, Resident #36 said, that three (3) staff members that are not allowed in her room anymore. Nurse Aide (NA) #139 was rude to her when her [MEDICATION NAME] (at surgical created stoma to drain urine from the bladder) bag busted opened. She said, that she was covered in urine. This was witnessed by a Licensed Practical Nurse (LPN) #73. She said, that the LPN came back in her room to take her statement, because she said that this incident had to be reported. She also stated that the Social Worker (SW) came to talk to her. She also stated that Licensed Practical Nurse (LPN) #16 refused to change [MEDICATION NAME] bag. It had leaked urine all over her. She said LPN #88 was always rude and snappy when she would ask her a question. She stated that she dreads it when she knows LPN #16 is going to work. She also stated that she had witnessed this same LPN #16 yell at another resident that does not know what she is doing at times. Looking for the reportable that was supposed to done on NA#139 could not be found. During a brief interview on 05/01/19 at 12:30 PM, with Registered Nurse-Unit Manager Director (RN-UM) #88, was asked if she could recall this event and if it was reported. She said yes, she gave the information to the Social (SW) #13 after the morning meeting. She was asked she filled out the, Adult Protective Services Mandatory Reporting Form. She replied no that she does not do that, she writes on a plain sheet of paper and that the SW fills those out. It this time she was also informed of the complaint about on LPN#16. During an interview on 05/01/19 at 1:45 PM, SW #13 was asked if she had completed the form for the reportable? She stated, that if she was handed any information about that she would have filled out the form and interviewed the resident. She stated that she will look again. She also informed about the complaint about LPN# 16. During a brief interview on 05/01/19 at 1:55 PM, with SW #13 stated that she cannot find where a report was done and maybe RN-UM #88 may not have given her the information. During a meeting on 05/01/19 at 2:00 PM, RN-UM #88 stated, that she remembers giving her SW # 13, the paper with the complaint on it. She was asked if she had made a copy for herself, and she replied no she did not. During a revisit on 05/01/19 at 3:25 PM, with Resident #36, SW #13 was in her room talking to her about both complaints one on NA#136 and LPN#16. 2. Resident #86 During an interview on 04/30/19 at 3:09 PM, Resident # 86 said, that Rehab Tech #58 hop changed her Wheel Chair (W/C) out for a different one and it is hard for her to get herself on and off of the toilet. She stated that LPN# 16 is hateful, rude, mean and likes to quarrel about having to help her out of the W/C to use the bathroom. She said, that she tells her that she can do it herself if she wanted to and that she is just being lazy. Resident #86 stated, that she feels like she has lost her rights. Resident # 86 stated she did not tell anyone because she is at the mercy of LPN #16 and she was afraid for her life because she does not know what she would do to get back at her. During an interview on 04/30/19 at 3:24 PM, RN-UM #88 was informed of allegation of LPN#16 being rude to Resident #86 and why she did not tell anyone about it. RN-UM#88 said she was not aware of any of this. She said she knows LPN #16 does not smile but she just assumed it was just her personality. She said that this nurse would be here tomorrow if I would want to talk to her. On 05/01/19 at 4:30 PM, SW #124 informed this Surveyor that a report is being done as we speak concerning NA#136 and LPN #16. She went on to say that NA# 136 will be told not to return to work until after the investigation has been completed. She stated, the LPN# 16 is being asked to leave now until after the investigation is also completed. Also a reoportable and investigation for Resident #86. She stated that they are going to interview all residents that had received care from LPN #16. During an interview on 05/02/19 at 10:00 AM, Administrator states, that she had not rested all night thinking about Resident #36 and the NA #136 and LPN #16. She said, that has had to write both of these people up for being rude and confrontational with co-workers. She went on to say that she knows that there has been two (2) major incidents with LPN #16 but can only find one write-up. She said that she should have known if LPN#16 is rude to her co-worker then she could be rude to the Residents and that is upsetting to her. She also states that NA #136 has also been written-up for bullying, gossiping, and making verbal threats towards her peers. She was counseled on 11/07/18 and 11/21/18 the final counseling was on 11/28/18 for continuing to bully, gossip and making verbal threats. On 05/02/19 at 10:30 AM, Social Worker # 124 provided three (3) reportable completed on 05/01/19. Two (2) were from Resident #36 about NA #136 and LPN #16. One (1) was from Resident #86 about LPN #16. b) 609 1. Resident #36 Facility policy titled, OPS300 Abuse Prohibition Revision Date: 07/01/18; - Identification of possible incidents and allegation which need investigation -Investigation of incidents and allegations -Reporting of incidents, investigations, and Center response to the results of their investigations. -Initiate an investigation within 24 hours if the event does not result in serious bodily injury. During an interview on 4/29/19 at 1:24 PM, Resident #36 said, that three (3) staff members that are not allowed in her room anymore. Nurse Aide (NA) #139 was rude to her when her [MEDICATION NAME] (at surgical created stoma to drain urine from the bladder) bag busted opened. She said, that she was covered in urine. This was witnessed by a Licensed Practical Nurse (LPN) #73. She said, that the LPN came back in her room to take her statement, because she said that this incident had to be reported. She also stated that the Social Worker (SW) came to talk to her. She also stated that Licensed Practical Nurse #16 (LPN) refused to change [MEDICATION NAME] bag. It had leaked urine all over her. She said LPN #88 was always rude and snappy when she would ask her a question. She stated that she dreads it when she knows LPN #16 is going to work. She also stated that she had witnessed this same LPN #88 yell at another resident that does not know what she is doing at times. Looking for the reportable that was supposed to done on NA#139 could not be found. During a brief interview on 05/01/19 at 12:30 PM, with Registered Nurse-Unit Manager Director (RN-UM) #88, was asked if she could recall this event and if it was reported. She said yes, she gave the information to the Social (SW) #13 after the morning meeting. She was asked she filled out the, Adult Protective Services Mandatory Reporting Form. She replied no that she does not do that, she writes on a plain sheet of paper and that the SW files those out. It this time she was also informed of the complaint about on LPN#16. During an interview on 05/01/19 at 1:45 PM, SW #13 was asked if she had completed the form for the reportable? She stated, that if she was handed any information about that she would have filled out the form and interviewed the resident. She stated that she will look again. She also informed about the complaint about LPN# 16. During a brief interview on 05/01/19 at 1:55 PM, with SW #13 stated that she cannot find where a report was done and maybe RN-UM #88 may not have given her the information. During a meeting on 05/01/19 at 2:00 PM, RN-UM #88 stated, that she remembers giving her SW # 13, the paper with the complaint on it. She was asked if she had made a copy for herself, and she replied no she did not. During a revisit on 05/01/19 at 3:25 PM, with Resident #36, SW #13 was in her room talking to her about both complaints one on NA#136 and LPN#16. c) 677 1. Resident #19 On 04/30/19 at 8:30 AM a request was made for registered nurse (RN) #88 to open the contractured left hand of Resident #19. While opening the hand there was a strong odor, the palm had an indentation from the nail on the ring finger, and the nail needed to be trimmed. Resident nurse #88 agreed the left hand needed cleaned and the nail cut. She completed both within a few minutes. d) 684 1. Resident #89 During an observation on 05/01/19 at 10:38 AM, Licensed Practical Nurse (LPN) #64 had pre-pulled the medications for Resident # 89 in the top draw of the medication cart he was using that day. He was asked about these cups of medications. He stated, that the resident was not in their room and that is why the cups of medications were in his cart. He was asked what he was going to do with the medication that he had pre-pulled. He stated that he was going to discard them. He was then asked if he was going to waste them than why had he took the time to write the room number and bed letter on each cup of medication. He said, well I guess you got me on that one 2. Resident #30 During an observation on 05/01/19 at 10:38 AM, Licensed Practical Nurse (LPN) #64 had pre-pulled the medications for Resident # 30 in the top draw of the medication cart he was using that day. He was asked about these cups of medications. He stated, that the resident was not in their room and that is why the cups of medications were in his cart. He was asked what he was going to do with the medication that he had pre-pulled. He stated that he was going to discard them. He was then asked if he was going to waste them than why had he took the time to write the room number and bed letter on each cup of medication. He said, well I guess you got me on that one 3. Resident #10 During an observation on 05/01/19 at 10:38 AM, Licensed Practical Nurse (LPN) #64 had pre-pulled the medications for Resident # 10 in the top draw of the medication cart he was using that day. He was asked about these cups of medications. He stated, that the resident was not in their room and that is why the cups of medications were in his cart. He was asked what he was going to do with the medication that he had pre-pulled. He stated that he was going to discard them. He was then asked if he was going to waste them than why had he took the time to write the room number and bed letter on each cup of medication. He said, well I guess you got me on that one 4. Resident #77 During an observation on 05/01/19 at 10:38 AM, Licensed Practical Nurse (LPN) #64 had pre-pulled the medications for Resident # 77 in the top draw of the medication cart he was using that day. He was asked about these cups of medications. He stated, that the resident was not in their room and that is why the cups of medications were in his cart. He was asked what he was going to do with the medication that he had pre-pulled. He stated that he was going to discard them. He was then asked if he was going to waste them than why had he took the time to write the room number and bed letter on each cup of medication. He said, well I guess you got me on that one 5. Resident #84 During an observation on 05/01/19 at 10:38 AM, Licensed Practical Nurse (LPN) #64 had pre-pulled the medications for Resident # 84 in the top draw of the medication cart he was using that day. He was asked about these cups of medications. He stated, that the resident was not in their room and that is why the cups of medications were in his cart. He was asked what he was going to do with the medication that he had pre-pulled. He stated that he was going to discard them. He was then asked if he was going to waste them than why had he took the time to write the room number and bed letter on each cup of medication. He said, well I guess you got me on that one 6. Resident #128 During an observation on 05/01/19 at 10:38 AM, Licensed Practical Nurse (LPN) #64 had pre-pulled the medications for Resident # 128 in the top draw of the medication cart he was using that day. He was asked about these cups of medications. He stated, that the resident was not in their room and that is why the cups of medications were in his cart. He was asked what he was going to do with the medication that he had pre-pulled. He stated that he was going to discard them. He was then asked if he was going to waste them than why had he took the time to write the room number and bed letter on each cup of medication. He said, well I guess you got me on that one 7. Resident #66 During an observation on 05/01/19 at 10:38 AM, Licensed Practical Nurse (LPN) #64 had pre-pulled the medications for Resident # 66 in the top draw of the medication cart he was using that day. He was asked about these cups of medications. He stated, that the resident was not in their room and that is why the cups of medications were in his cart. He was asked what he was going to do with the medication that he had pre-pulled. He stated that he was going to discard them. He was then asked if he was going to waste them than why had he took the time to write the room number and bed letter on each cup of medication. He said, well I guess you got me on that one 8. Resident #140 The facility failed to follow physician's orders for nebulizer administration. The physician ordered albuteral nebulizer treatments every four (4) hours. The order was transcribed incorrectly on 04/23/19 instead to every four (4) hours as needed. From 04/23/19 through 04/30/19 she received only three (3) albuteral neb treatments as follows: 04/23/19 at 2045; 04/24/19 at 10 AM; 04/26/19 at 8:40 AM. The medical record was reviewed on 05/01/19. Resident #140 has [MEDICAL CONDITIONS]. Prior to a (MONTH) 2019 hospitalization , she had physician orders for [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) nebulizer treatments every four (4) hours for dyspnea, wheezing, and cough. Review of the medication administration record(MAR) for early (MONTH) pre-hospitalization dates found she took it around the clock with few exceptions. Review of the hospital discharge summary dated 03/28/19 found that the hospital recommended that she continue the same nebulizer treatments upon return to the nursing home. Review of the facility's physician order sheet and interim plan of care dated 03/28/19 contained orders for Albuteral nebulization treatments every four (4) hours for shortness of breath. The facility physician signed those orders on 03/29/19. Review of the March, 2019 MAR found an order for [REDACTED]. Review of the (MONTH) 2019 MAR found she continued to receive albuteral nebulization treatments every four (4) hours which she consistently accepted. Further review of the (MONTH) 2019 MAR found that the facility changed over to electronic health records (EHR) on 04/23/19 in the evening. The EHR MAR indicated [REDACTED]. Review of the (MONTH) MAR from 04/24/19 through 04/30/19 found she received only two (2) albuteral nebulization treatments. One occurred at 10 AM on 04/24/19, and the other occurred on 04/26/19 at 8:40 AM. An interview was conducted with the corporate quality services registered nurse #155 (CQS #155) and the director of nursing (DON) on 05/01/19 at 2:30 PM. It was discussed that on 03/28/19 instead of the [MEDICATION NAME] ([MEDICATION NAME]-albuteral), the nurse who reconciled the orders instead wrote only albuteral nebulization treatments. According to the manufacturer's guidelines, this delivered .5 milligrams less Albuteral than did the [MEDICATION NAME]. The CQS and DON said the physician signed the re-admission orders [REDACTED]. The CQS said that a transcription error must have occurred when the facility switched to EHR on 04/23/19, which led to the resident receiving the Albuteral nebulization treatments only every four (4) hours prn (as needed) rather than every four (4) hours around the clock as the physician ordered. An interview was conducted with the CQS and nurse practitioner #158 (NP #158) on 05/01/19 at 2:45 PM. They said there were no physician orders to discontinue the Albuteral nebulization treatments ordered every four (4) hours. They said there were no new physician orders to administer Albuteral nebulization treatments every four (4) hours prn. The CQS agreed that the facility failed to follow physician orders for the Albuteral nebulizer treatments every four (4) hours following the 04/23/19 change over to EHR system. NP #158 said she will assess the resident today, and see if the resident is able and agreeable with keeping the nebulization treatments every four (4) hours prn. 9. Resident #130 Observation on 04/29/19 at 3:57 PM revealed Resident #130 with bilateral contractures of the hands with no devices in place. Review of the medical record revealed he has palm protectors ordered. Observation on 05/01/19 at 5:00 PM found a folded washcloth in his right hand. He used a communication board to say they keep a supply of washcloths in his bedside stand. During an interview with his nurse aide #14 (NA #14) at this time, she said they use a washcloth in the right hand only. She said she thought this was because the index finger on his right hand was bent downward and inward, and they were trying to protect the skin integrity of his palm. Review of the medical record on 05/01/19 at 5:30 PM found current physician orders as follows: {typed as written} Palm Protectors With Finger Separators to Right Hand. Wear As Tolerated. Remove For Hygiene. every day and night shift. Review of the care plan on 05/01/19 at 5:30 PM revealed an intervention initiated 04/15/19 as follows: {Typed as written} Palm Protectors With Finger Separators to Right Hand. Wear As Tolerated. Remove For Hygiene. An interview was conducted with licensed nurse #140 (LPN #140) on 05/01/19 at 5:43 PM. She said they use a washcloth in his right hand, not a palm guard with finger separators. She said he has no wounds of any type at this point in time. An interview was conducted with occupational therapy employee #152 (COTA #152) on 05/02/19 at 8:00 AM. She said they (therapy) recommended he use a palm protector with finger separators if tolerated. If not tolerated, she said that he can use washcloths. She was informed that he was care planned for the palm protector with finger separators to the right hand, not the wash cloth, yet staff were using only a washcloth. Relayed that nothing is used in the left hand. She said she would speak with the therapy director about this, who in turn will be in contact with nursing. An interview with the assistant director of nursing (ADON) and the corporate quality services registered nurse #155 (CQS #155) on 05/02/19 at 12:45 PM found that a new order from the physician was entered into the electronic medical record (EHR) this morning for a washcloth to the right hand. The ADON said she revised the care plan today to reflect that change. At approximately 1:00 PM on 05/02/19 the director of nursing (DON) provided a copy of a verbal physician order dated 05/01/19 at 10:49 PM which stated the following: {typed as written} Resident To Have Wash Cloth in right Hand as tolerated. (MONTH) Remove For Skin Checks & (symbol for and) Hygiene. The start date for this order was the 7 a - 3 p shift on 05/02/19. 10. Resident #44 The medical record was reviewed on 04/30/19. Review of the recapitulation of physician's orders for (MONTH) and (MONTH) 2019 found physician orders to administer [MEDICATION NAME] Insulin ten (10) units subcutaneously with meals related to diabetes mellitus. It included directives to withhold the insulin if the blood sugar was less than 150 milligrams/deciliter (mg/dl). Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Per physician's orders, the insulin should have been withheld. However, the nurse administered ten (10) units of [MEDICATION NAME] insulin. Also, at 7:30 AM on 04/24/19 and on 04/25/19 the space in which to document the blood sugar results and the administration of insulin was left blank. During an interview with the director of nursing (DON) on 04/30/19 at 3:00 PM, it was discussed that the resident received ten (10) units of [MEDICATION NAME]on 04/26/19 at 7:30 AM when the blood sugar was only 106 mg/dl. She agreed that the insulin should have been withheld. It was also discussed that at 7:30 AM on 04/24/19 and on 04/25/19 there was no evidence as to the blood sugar result and/or if the insulin was given or was held. The DON agreed and offered no further explanation. An interview was conducted with the administrator on 05/01/19 at 9:45 AM. She was informed that on 04/26/19 at 7:30 AM this resident received insulin when she had a blood sugar reading of 106 mg/dl. It was discussed that the physician set a parameter directing to not give the insulin with meals when the blood sugar was less than 150 mg/dl. It was also discussed that there was no evidence on 04/24/19 and 04/25/19 at 7:30 AM if the nurse followed the physician's order to assess the blood sugar at that time and administer insulin. No further information was provided prior to exit. 11. Resident #4 In an interview on 04/30/19 at 4:18 PM, Resident #4 said she has sores on both legs, the fluid builds up, and drain out of her legs. Resident #4 said her treatment is to have her legs wrapped. Resident #4 scored a 12 on her Brief Interview for Mental Status (BIMS)on a significant change of status. 01/23/19. A score of 8-12 indicates moderately impaired cognitively. Under section B, the Resident makes self-understood is coded as understood, and the resident's ability to understand others is coded as understands clear comprehension. On 04/30/19 at 2:53 PM, Licensed Practical Nurse (LPN) #6 said the resident is taking a diuretic medication ([MEDICATION NAME] and [MEDICATION NAME])( a diuretic increase urine production in the kidneys, promoting the removal of salt and fluid from the body). LPN #6 revealed that Resident #4 has an order to have her legs wrapped every week, but the resident refuses to have her legs wrapped in the summer due to it is too hot. The LPN thought the Physical Therapy was wrapping Resident #4's legs. Observation of Resident #4's bilateral legs with LPN #6 on 04/30/19 at 3:07 PM, found the resident's legs were not wrapped. Resident's #4's legs were [MEDICAL CONDITION] and had a flaky loose scale. The LPN #6 picked up resident #4's right leg and the observation revealed an open [MEDICAL CONDITION] on the back of her leg, and knee which both were red, and weeping clear fluid. There was a brown crusty scab around the open areas. The left lower leg was excoriated red, with a hard, rough, brown scab of dried blood. There was multiple open lesion on her left leg. Observed a sheet underneath Resident #4's legs which had dried brown/burgundy stains on the sheet. LPN #6 was asked why Resident #4's legs not wrapped. LPN #6 did not make a comment. A review of Resident #4's physician order dated 03/13/19. The physician order states to cleanse venous ulcer to left lateral leg with wound cleanser pat dry, apply Optilock and wrap with fourflex wraps every seven (7) days and whenever needed (PRN). The physician order for [REDACTED]. A review of Resident #4's nursing notes on 04/30/19 at 3:11 PM, found LPN #6 had documented Resident #4 had refused to have treatment to her left leg wounds on 04/24/19. A review of Treatment Administration Sheet (TAR) found no one signed off for the treatment to Resident #4's left leg wound on 04/17/19. The LPN #6 wrote refused on the TAR for 04/24/19. The record finds the Nurse Practitioner (NP) and/or the physician was not notified of Resident #4 refusing her treatment to her left leg on 04/24/19 or why the staff did not follow the physician order to treat Resident #4's left leg on 04/17/19. A review of the TAR for the right leg wound treatment found no signatures on 04/18/19 and 04/25/19. There were no notification to the NP and/or physician of why the treatment was not performed as ordered. When LPN #6 was asked why she did not follow the physician order for [REDACTED].#6 stated that, Nurse Practitioner (NP) #157 was on duty that day. LPN #6 confirmed that she did not notify the NP that Resident #4 refused her treatment on 04/24/19. The LPN stated she did not know why Resident #4 did not receive her wound treatment to her left leg on 04/17/19. LPN #6 also acknowledge Resident #4 did not receive treatment to her right leg on 04/18/19 and 04/25/19. In an interview with NP# 157 on 04/30/19 at 3:15 PM, the NP was asked whether the staff informed her Resident #4 had refused her treatment to her left leg, or the staff was not following the physician order to treat Resident #4's right or left leg at any time in (MONTH) 2019, the NP stated that, the staff did not notify her of the wound treatment not being done for Resident #4's right and left leg for the month of (MONTH) 2019. The Center Nurse Executive (CNE) #22 confirmed the treatment to Resident #4 was not performed by her staff as the physician ordered for the left leg on 04/17/19 and 4/24/19. The CNE agreed that Resident #4's right leg treatment was also not performed on 04/18/19 and 04/25/19. The CNE agreed that her staff did not notify a physician nor an NP of the resident's refusal to have her treatment to her left leg and/or why they did not follow the physician order to performed Resident #4's treatment to her right and left leg for the above dates. 12. Resident #116 During Resident Council meeting on 04/30/19 at 10:00 AM Resident #116, whom has an intact cognitive ability, expressed a concern with staff answering call bells timely. At times there is a forty-five (45) minute wait after pressing the call bell before staff responds to assist in changing a soiled brief. Nine other residents at the meeting agreed call bells are often not answered in a timely manner. 13. Resident #108 Resident #108 had an order written [REDACTED]. Ten (10) days of antibiotics twice a day meant Resident #108 should have received 20 doses of [MEDICATION NAME]. Review of Resident #108's Medication Administration Record [REDACTED]. During an interview on 05/01/19 at 5:58 PM, the Unit Director and the Facility Director of Nursing confirmed Resident #108's MAR indicated [REDACTED]. No further information was provided through the completion of the survey. 14. Resident #154 Resident #154 was admitted to the facility 04/11/19. Resident #154 received total [MEDICATION NAME] nutrition (TPN) therapy, a method of infusing fluids into a vein to bypass the gastrointestinal tract and provide nutrients needed. Resident #154 had the following orders: - Weigh every day shift, every Thursday, written on 04/11/19, to start 04/18/19 - Weigh one time a day, every 7 day(s) for monitor for 4 weeks until finished, written on 04/23/19, to start 04/23/19, to end 05/21/19 Review of Resident #154's medical records revealed the only weight recorded for the resident was an admission weight on 04/11/19. During an interview on 05/01/19 at 11:42 AM, Corporate Quality Services Registered Nurse verified Resident #154's weight had not been recorded since admission. She stated Resident #154's weight would be obtained immediately. Resident #154 also had an order for [REDACTED]. Review of Resident #154's medical records revealed no laboratory testing performed on 04/15/19. Laboratory testing consisting of a complete blood count and comprehensive metabolic panel was performed on 04/16/19. During an interview on 05/01/19 at 3:15 PM, the Director of Nursing confirmed Resident #154 did not have laboratory testing on 04/15/19. She stated Resident #154 did have laboratory testing performed on 04/16/19 but confirmed this laboratory testing did not include a magnesium level and phosphorus level as ordered by the physician to be performed weekly. No further information was provided through the completion of the survey. 15. Resident #78 Resident #78 had an order written [REDACTED]. (Order typed as written.) [MEDICATION NAME] is an antipsychotic medication that can cause elevated blood glucose levels. An Accu-Check test involves the nurse obtaining a drop of blood from the resident's fingertip to check the blood glucose level. Review of Resident #78's Medication Administration Record [REDACTED]. Resident #78's progress notes did not document a blood glucose level for 05/01/19. On 05/02/19 at 11:15 AM, Licensed Practical Nurse (LPN (TRUNCATED)",2020-09-01
693,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,880,F,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review, and review of infection control surveillance records and line listings, the facility failed to establish and maintain an infection control and prevention program designed to help prevent the development and transmission of communicable diseases and infections to the extent possible. The facility failed to isolate a resident with pneumonia who had a positive sputum culture with a multi-drug resistant organism (Resident #103). The facility failed to culture a draining wound (Resident #256). The facility failed to identify and document on infection control line listings a resident who was prescribed antibiotic therapy (#130). The facility failed to review their infection control and prevention policies and procedures at least annually. Other infection control infractions included a leaking shower in a commonly shared unit shower room , dirty gloves lying on the floor of a commonly shared unit shower room, a green mat left spread across a toilet to dry in a bathroom connected to a commonly shared unit shower room, a Foley catheter tubing dragging the floor (Resident #126), and the ice chest used to dispense fresh ice to residents was left open in the residents' hallway when not in use. A commonly shared Glucometer was not cleaned appropriately between each resident's use. The laundry room did not have negative air pressure between the clean and dirty side of the laundry area. A nurse failed to perform hand hygiene between administration of medications to multiple residents. A nurse placed resident medications directly into her bare hands prior to placing the medications into portion cups. Staff stored personal items in a medication cart. A nurse failed to maintain effective infection control practice during wound care for Resident #36. These deficient practices had the potential to affect all residents in the facility. Resident identifiers: #103, #256, #130, #126, #36. Facility census: 155. Findings include: a) Infection control surveillance 1. Resident #103 Infection control line listing review were reviewed with infectious disease/infection control registered nurse #160 (RN #160) beginning at 3:30 PM on 05/01/19. The (MONTH) 2019 infection control monthly line listing included Resident #103 who was diagnosed with [REDACTED]. Per the (MONTH) line listing the chest x-ray was positive for pneumonia, and the sputum culture was positive [MEDICAL CONDITION] on 01/23/19. He was treated with one (1) dose of [MEDICATION NAME], followed by Cefepine every eight (8) hours intravenously for seven (7) days and [MEDICATION NAME] twice daily intravenously for ten (10) days. The precaution type listed was standard precautions. An interview was conducted with Infection control/infectious disease registered nurse #160 (RN #160) on 05/01/19 at 4:30 PM. She said they did not initiate isolation precaution for this resident. When asked why, she said because he was with it. She said he was able to wash his hands and to perform cough etiquette. Review of the medical record on 05/02/19 found a sputum culture was collected on 01/24/19 at 1:55 PM. The final report was verified on 01/26/19 at 9:32 AM as having a moderate growth [MEDICAL CONDITION]. It included a flag which called for attention to follow contact precautions. This warning was followed by two (2) exclamation marks. A physician's orders [REDACTED]. The physician also ordered a consult to Nurse Pro for midline placement for intravenous antibiotic infusions. Review of the MAR found he received Cefepine two (2) grams every eight (8) hours from 01/24/19 through 01/30/19. Also, he received [MEDICATION NAME] 1230 milligrams twice daily from 01/24/19 through 02/02/19. On 05/02/19 at 9:30 AM an interview was conducted with corporate quality services registered nurse #155 (CQS #155), the director of nursing (DON) and RN #160. It wad discussed that the resident had a positive sputum culture [MEDICAL CONDITION], had a [DIAGNOSES REDACTED]. The DON said that was a hospital laboratory culture slip and that they do things differently in a hospital. They were asked how they could be certain that he always practiced cough etiquette, even in his sleep. They were asked how they could be certain he washed his hands properly all the time. They were asked how they could be certain that a staff person would not enter his room and pick up [MEDICAL CONDITION] organism on their clothing and carry it to another room to a vulnerable resident. They did not provide an answer. 2. Resident #256 Infection control line listings were reviewed with registered nurse #160 (RN #160) on 05/01/19 beginning at 3:30 PM. The (MONTH) (YEAR) infection control monthly line listing included Resident #256 who was diagnosed with [REDACTED]. Per the line listing, the facility practiced standard precautions. During an interview with RN #160 on 05/01/19 at 4:30 PM, she said there was no culture obtained of the drainage from the rectal abscess. She said the antibiotic therapy was prescribed by physicians due to the appearance of the wound and its drainage, rather than by culture. On 05/01/19 at 9:00 AM an interview was conducted with RN #160. She said they face timed with Third Eye and the physician saw the purulent drainage. Review of a follow-up progress note dated 12/23/18 at 8:49 AM stated: Physician examined resident via TEH Video. Resident had a moderate amount of thick purulent drainage from both his right underarm and perianal and rectal area. Physician ordered a PICC (Peripherally Inserted Central Catheter) line placement and the following antibiotics. [MEDICATION NAME] one (1) gram q. (every) 24 hours and [MEDICATION NAME] 3.375 grams q. 6 (six) hours, both to be administered x (symbol for times) 10 (ten) days. In-house physician to evaluate resident during next visit.Nurse Pro contacted and scheduled for PICC line placement for 12:00 PM today. RN #160 was asked why no culture or sensitivity of the draining wound was obtained. She said she did not know for sure. An interview was conducted with the director of nursing (DON), infection control registered nurse #160, and the corporate quality services employee # 155 (CQS) on 05/02/19 at 9:30 AM. It was discussed that there was an issue when intravenous antibiotics were prescribed, and administered, to treat a resident's wound without first obtaining a culture of what the facility described as thick, purulent drainage, to find the identity of the causative organism. It was discussed that this practice prohibits knowing with certainly if an organism is susceptible or resistant to various antibiotics. It was also discussed that they had no way of knowing if this resident's wounds contained multi-drug resistant organisms which may require contact precautions. No further evidence was provided prior to exit. 3. Resident #130 An interview was conducted with infectious disease/infection control registered nurse #160 (RN #160) on 05/01/19 at 3:30 PM. She said formerly the facility used all paper, hard-copy charting and documentation. She said that because of that system, she needed to rely on the nurses to notify her of new orders for antibiotic therapy. She said if nurses failed to notify her of new orders for antibiotic therapy, there was a chance that some infections could have gotten missed on her line listings or infection control reports. She said the facility changed to electronic health records (EHR) on 04/23/19. Review of Resident #130's medical record on 05/01/19 at 5:30 PM found a physician's orders [REDACTED]. Further review of the medical record revealed that nursing staff documented on the (MONTH) 2019 Medication Administration Record [REDACTED]. daily from 03/23/19 through 03/29/19 for a total of seven (7) doses. Per the MAR, the resident received [MEDICATION NAME] for the [DIAGNOSES REDACTED]. An interview was conducted with RN #160 on 05/02/19 at 11:30 AM., in the presence of corporate quality services registered nurse #155 (CQS #155). RN #160 provided a copy of the (MONTH) 2019 infection control monthly line listing. She agreed that Resident #130 was not including in the (MONTH) 2019 surveillance. Per the monthly line listing, the resident's name, room number, admitted , date of onset of the infection, notation as to whether it was a health care associated infection or community acquired infection, type of symptoms/diagnosis, culture/chest x-ray date and results, antibiotic type with start date, date of resolution of infection, and the precaution type could have been completed for this infection but was not completed. She agreed this information should have been completed on the infection control monthly line listing for surveillance, tracking/trending, and audit purposes, and was not. She said this infection was overlooked in surveillance records. 4. Infection Control and Prevention Policy and Procedure Manual An interview was conducted with the director of nursing (DON), administrator, corporate quality services (CQS) registered nurse #155, and the infection control/infectious disease registered nurse #160 (RN #160) on 05/02/19 at 12:15 PM. They said they were unable to provide evidence that their infection control and prevention policy and procedure manual was reviewed and/or revised annually, or at least was done within the past year. A request was made to see the most recent Infection Control and Prevention Policy and Procedure manual review date. This information was not provided prior to exit. b) Resident #126 Shower leaking underneath the floor of the shower and out onto hallway tile, Foley Catheter tubing dragging on floor for Resident #126, ice chest left open in hallway, shower room had dirty gloves and wet green mat drying on the toilet, 1. Leaking water from the third-floor shower head underneath the flooring of the third-floor shower room and onto the hallway tile floor. Observation on 5/1/19 at 2:00 PM, revealed tile in the hallway was black and gray in color outside of the third-floor shower room. There was a green color mat in front of the shower door. When you opened the shower door the threshold had a towel laying in the threshold in which it was soaked with water. When you enter the shower room the flooring had water seeping out from under the flooring. An interview with the DES #97 was conducted on 5/1/19 at 3:45 PM, stated when you turn the shower head on the water leaks under the flooring of the shower room and continues underneath the tile in the hallway. The DES #97 said he only had knowledge of the floor leaking water underneath the flooring in the shower room and under the tile floor in the hallway for about two weeks. The DES #97 said someone from (company name) is to come and fix the flooring within 30 days. The DES #97 revealed the housekeepers change the green mats around 7:00 AM, and then about 11:00 PM. The DES #97 confirmed the nursing staff continued giving residents showers in the third-floor shower room. The DES #97 showed surveyor the housekeepers had changed the mats about an hour ago. The green mat hung over the shower room toilet. This toilet is used by the residents. The Observation and feeling the green mat revealed the mat was completely soaking wet and the DES #97 pointed at the towel which was at the threshold of the shower room and the hallway. The towel was soaked with water and very wet seeping out in the hallway across the threshold. The facility staff had one (1) yellow caution wet floor sign past the leaking water under the tile floor in the hallway. This put Residents, facility employees and the public at risk for injury. The DES #97 was asked whether he could stop all water to the main shower room on the third floor and he said the staff told him that would make them take their resident down stairs to get a shower. He said this is a dignity issue. The DES #97 said the nursing staff is having to walk and pull the resident shower Bed, and wheelchair over the wet tile floor, green mat, and the towel. The DES #97 was asked is this not dangerous and he said yes, it is. The DES #97 said he was told it might be 30 days. During this time frame, the facility had knowledge of this issue and still had not corrected the problem. This procedure has the potential for residents, facility staff and the public who visit that area could slip and fall resulting in a serious injury. The wet flooring is a safety hazard the wet floor sign is not located in an area adjacent to the slippery floor area. This created a potential for individuals (residents, facility staff, and the public) to slip and fall resulting in a serious outcome. On 05/02/19 at 11:00 AM, observed a yellow caution wet floor sign in front and behind the leaking water under the hallway floor tile. There was a notice on the shower door that said Shower out of use this AM. Yellow and black tape caution crissed crossed on the third-floor shower door that said caution wet floor. There were two notices near the third-floor shower hall that said, sorry in red letters, temporary closed. There was another sign saying notice in blue lettering, temporary out of service. On 05/02/19 at 8:30 AM, the Administrator of the facility confirmed that she knew about the third-floor shower room leaking water from the drain under the floor in the shower room, and out under the tile floor in the hallway for about three (3) weeks. The Administrator said she had called Family carpet and they are to come and replace the flooring. The Administrator was asked to view the information she had related to family Carpet fixing the floor of the third-floor shower room. The Administrator at the time of exiting the facility did not provide any information related to Family Carpet coming to fix the third-floor shower room flooring and hallway tile floor. In an interview on 05/02/19 at 11:15 AM, with the Assistant Director of Nursing (ADON) #122, said they took the shower out of use this AM. The ADON stated that, we are going to use the second-floor shower. 2. Resident #126 On 05/01/19 at 11:04 AM,, Assistant Director of Recreation (ADR) #31 was pushing Resident #126 down the hallway to the nursing station with the resident's Foley Catheter bag tubing dragging the floor. The Assistant Director of Nursing ( ADON) 122, was present and stated they should have put his Foley catheter bag up high enough to prevent it from dragging the floor. 3. Ice chest left open in the hallway Surveyor walked up to the nursing station desk on the third floor on 05/01/19 at 3:45 PM. Resident #26 said hey, the staff left the ice box open. Surveyor walked on over next to the elevator and the ice chest was open to air with ice inside the ice chest. Licensed Practical Nurse (LPN) #103 was walking by, and agreed the icebox should have been covered. 4. Dirty gloves, shampoo and body wash, and a wet mat on the toilet. Observation of the unlocked third floor shower room on 05/01/19 at 5:20 PM, found one (1) pair of used gloves on the sink, one (1) pair of used gloves on the floor next to the garbage container and one (1) pair of used gloves on the floor next to the dirty linen. There was one (1) bottle of provon shampoo and body wash open, stay away from children. The bottle direction said if you swallow this product you must contact the poison control center. A wet green mat was laying over the toilet left to dry out. In an interview on 05/01/19 at 5:30 PM, with the ADON #22, she acknowledges all the above infection control issues in the third-floor shower room. A review of the safety data sheet for the Provon tearless shampoo and body wash hazard identification: causes serious eye irritation. c) Glucometer cleaning On 05/02/19 at 10:50 AM observation of a medication cart on the third floor found a glucometer and alcohol swaps. Licensed nurse (LPN) #140 explained the glucometer is cleaned with alcohol swaps between residents and with a wipe containing bleach when returned to the medication room. Review of the Food and Drug Administration (FDA) recommendations for cleaning glucose monitors between patient use is, The disinfection solvent you choose should be effective [MEDICAL CONDITION](human immunodeficiency virus), [MEDICAL CONDITION], and [MEDICAL CONDITION] virus. Outbreak episodes have been largely due to transmission of [MEDICAL CONDITION] and [MEDICAL CONDITION]. However, of the two [MEDICAL CONDITION] virus is the most difficult to kill. Please note that 70% [MEDICATION NAME] (alcohol) solutions are not effective against [MEDICAL CONDITION] bloodborne pathogens. d) Laundry room Observation of the laundry room on at 11:15 on 05/02/19 found the laundry room did not have negative pressure to prevent the air from soiled side of the laundry from entering the clean side of the laundry room. On 05/02/19 at 11:35 AM the director of environmental services, #97 expressed the exhaust fan in the dirty laundry room does not have enough suction to move the air in a manner to create negative air pressure for the clean laundry room. e) Facility task - medication administration At 05/02/19 at 7:56 AM, Licensed Practical Nurse (LPN) #200 was observed during medication administration. LPN #200 was observed administering oral medications to a resident in the hallway. She then prepared and administered oral medications to a resident in the dining area. LPN #200 then prepared and administered oral medications to another resident in the dining area. LPN #200 did not perform hand hygiene between medication preparation and administration to different residents. LPN #200 had no comment regarding the matter. On 05/02/19 at 10:15 AM, the Clinical Quality Services Registered Nurse was informed LPN #200 did not perform hand hygiene between medication preparation and administration to different residents. No additional information was provided through the completion of the survey. f1) Medication administration During an observation of medication administration on 05/01/19 at 9:05 AM, Licensed Practical Nurse (LPN) #16 was popping medications from a medication card, when it was noted that she popped the pill into her hand than placed it in the medication cup with other medication. With surveyor intervention she disposed of the cup of medications and started all over popping all medications from the card directly into the medication cup. LPN #16 agreed that she should have not popped the medication into her hand first. f2) Hand hygiene during a medication pass During an observation of hand washing during a medication pass on 05/01/19 at 9:10 AM, LPN #16 failed to use proper hand hygiene. She turned the water on, put her hands under the running water for 4 seconds, she than turned the water off with her wet hand and dried her hands. She was asked if she used proper hand washing technique. She asked if she needed to wash her hands again. She was asked if she knew what the facility polcy was on hand hygiene. She did wash her hands again. During a brief interview on 05/01/19 at 10:40 AM, Registered Nurse- Unit Manager #88 was informed of the infection control failures. She had no comment. f3) Staff personal Items found in a medication cart During an observation on and interview on 05/01/19 at 10:15 AM, Licensed Practical Nurse (LPN) #64 opened the medication cart for surveyor check and there was a soft blue lunch box and a soda in a bottle. He was asked what was that? He stated, that it was he lunch. He was informed that it was an infection control issue for him to store his personal items in the medication cart used for the residents. He stated, well what do you want me to do mt wallet is also in there because I don't have any place safe to keep my things here? He then removed the items and took them to the medication storage room. f4) medication storage During an observation on and interview on 05/01/19 at 10:15 AM, Licensed Practical Nurse (LPN) #64 opened the medication cart for surveyor inspection. It was discovered there was not a cap on the multi-use bottle of [MEDICATION NAME] nasal spray, belonging to Resident #225. LPN #64 said, that he had not noticed. During a brief interview on 05/01/19 at 10:40 AM, Registered Nurse- Unit Manager #88 was informed of the infection control failures. She had no comment. g) Resident #36 During an observation on 05/02/19 at 7:52 AM, LPN #103 was removing the dressings on the buttock on Resident #36 when the RN-UM #88 prompted LPN #103 to remove the dressing from the left shoulder area before the ones on the buttock area, then again, the clean the area on the shoulder first and to wash her hand. Surveyor intervention stopped LPN# 103 from repeated use of a gauze used to clean the wounds using the front and back of the gauze and on only one wound. RN-UM #88 intervened to explain how to apply the dressing on the left gluteal fold. LPN #103 told NA #43 to hold the absorbent pad in place while she opened dressing NA #43 did it without thinking about changing his gloves as he should have to prevent an infection to the wound. LPN #103 asked if she should wash her hands more than once, she was not organized taking longer than it should have taken. Resident # 36 reminded her that she had not had anything to eat yet. It was 9:08 AM, instead of setting up as her table with all the items she would need to use for each wound site she fumbled around and repeatedly asked for RN-UM #88 to open things. Areas were the left shoulder, multiple Pressure wounds on the buttock and gluteal folds, left and right foot. On 05/01/19 at 3:45 PM, RN-UM #88 provided a paper that showed she had started a re-education with LPN #13 and #64 on hand washing, proper dispensing of medications, no storage of personal items with resident medication.",2020-09-01
694,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,881,D,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of infection control line listings, medical records, and staff interview, the facility failed to practice antibiotic stewardship when it failed to justify the use of antibiotic therapy for a draining wound that was not cultured. This was evident for one (1) of eight (8) residents reviewed on the (MONTH) (YEAR) infection control monthly line listing. Resident identifier: #256. Facility census: 155. Findings include: a) Resident #256 Infection control line listings were reviewed with registered nurse #160 (RN #160) on 05/01/19 beginning at 3:30 PM. The (MONTH) (YEAR) infection control monthly line listing included Resident #256 who was diagnosed with [REDACTED]. Per the line listing, the facility practiced standard precautions. During an interview with infectious disease/infection control registered nurse #160 (RN #160) on 05/01/19 at 4:30 PM, she said there was no culture obtained of the drainage from the rectal abscess. She said the antibiotic therapy was prescribed by physicians due to the appearance of the wound and its drainage, rather than by culture. On 05/01/19 at 9:00 AM an interview was conducted with RN #160. She said they face timed with Third Eye and the physician saw the purulent drainage. Review of a follow-up progress note dated 12/23/18 at 8:49 AM stated: Physician examined resident via TEH Video. Resident had a moderate amount of thick purulent drainage from both his right underarm and perianal and rectal area. Physician ordered a PICC (Peripherally Inserted Central Catheter) line placement and the following antibiotics. [MEDICATION NAME] one (1) gram q. (every) 24 hours and [MEDICATION NAME] 3.375 grams q. 6 (six) hours, both to be administered x (symbol for times) 10 (ten) days. In-house physician to evaluate resident during next visit.Nurse Pro contacted and scheduled for PICC line placement for 12:00 PM today. RN #160 was asked why no culture or sensitivity of the draining wound was obtained. She said she did not know for sure. An interview was conducted with the director of nursing (DON), RN #160, and the corporate quality services employee #155 (CQS) registered nurse on 05/02/19 at 9:30 AM. It was discussed that there was an antibiotic stewardship practice issue when intravenous antibiotics were prescribed, and administered, to treat a resident's wound without first obtaining a culture of the facility-described thick, purulent drainage, to find the identity of the causative organism. It was discussed that this practice also prohibits knowing with certainly if an organism is susceptible or resistant to various antibiotics. It was also discussed that they had no way of knowing if this resident's wounds contained multi-drug resistant organisms which would require contact precautions. No further evidence was provided prior to exit.",2020-09-01
710,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2019-08-14,641,E,0,1,KL5911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, facility failed to ensure the Minimum Data Sets (MDS) accurately reflected the resident's status. This was true for 3 of 21 resident assessments reviewed during the Long-Term Survey Process (LTCSP). Resident #121's MDS was inaccurate in the area of prognosis/death in the facility. Resident #93's MDS was inaccurate in area of contractures. Resident #61's MDS was inaccurate in area of weight. Resident identifiers: #121, #93, and #61. Facility census: 115. Findings included: a) Resident #121 Resident #121 was admitted to the facility on [DATE] from an acute care facility. Further review of medical records found a progress note written by the Family Nurse Practitioner on 07/09/19, which read, .Family has declined hospice services. Prognosis is poor- [MEDICAL CONDITION] with a history of [MEDICAL CONDITION], dysphagia, dementia end stage Palliative care- comfort measures- no further tube feedings. Discussed plans with nursing and social services . On 07/12/19 the resident was found unresponsive and absent of vital signs. Review of the MDS with an assessment reference date (ARD) of 07/11/19 was marked, Admission. Review of section J 1400 Prognosis was marked to indicate the resident did not have a condition or chronic disease that may result in a life expectancy of less than six (6) months. Interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 08/13/19 at 1:00 pm, confirmed the resident had declined steadily from the admission to the facility on [DATE] and the MDSs with ARD of 07/11/19 was inaccurately coded. They both agreed the MDS should have been coded, Life expectancy of less than six (6) months. b) Resident (R#93) Initial observations and resident interview, on 08/12/19 at 01:54 PM, revealed both resident's hands were severely contracted and prevented her from doing certain hand movements. The resident said she had [MEDICAL CONDITION] Arthritis for years and had caused her hands to be like this. The resident's knuckles were swollen, and all her fingers were misaligned and bent out of shape. The joints were deformed on both hands. All her fingers were pulled side-ways toward the outer edge of her hands, with some fingers overlapping each other. R#93 said doing somethings were impossible to do and other things very difficult like trying to button a shirt. Review of the resident's quarterly minimum data set (MDS) with an assessment reference date (ARD) 07/10/19, on 08/13/19 at 12:18 PM, revealed the resident has clear speech and always makes herself understood and always understands. The resident's Brief Interview for Mental Status (BIMS) score was fifteen (15) indicating the resident is cognitively intact. R#93 needs extensive assistance with dressing, toileting, personal hygiene, and bathing; limited assistance with bed mobility and transfers; and needs supervision with eating. Resident has impairment in both upper extremities. A pertinent [DIAGNOSES REDACTED].#93 is on scheduled and PRN (as needed) pain medication. In the MDS assessment of contractures is found in section 'S' Functional Status. The MDS S3100 Contractures coding options included various areas of the body starting with [NAME] Hand which was marked '#0' indicating none or no contractures of the indicated the resident's dominant side was her Right side. The MDS S3200B Use of Dominant Hand/Arm. To what extent does the resident have use of his/her dominant hand/arm? Coding choices were 1. Full or 2. Limited or 3. None. Full was marked indicating the resident had full use of her right dominant hand. On 08/13/19 at 01:40 PM, review of physician orders [REDACTED]. times a day for pain and Biofreeze Professional 5% Gel (Menthol (Topical [MEDICATION NAME])) Apply to R (right) hand/knuckles topically two times a day for pain. On 08/13/19 at 01:59 PM review of careplan revealed no focus area to address functional mobility concerning contractures of both hands. The care plan was not individualized to reflect the resident's needs concerning her hand contractures. An interview with MDS #92, on 08/13/19 at 04:20 PM, revealed in section S Z. Other was marked referring to the resident's fingers. When asked why hands were not designated since the knuckles above the fingers were also affected, MDS #92 could not give an answer and said she would have to look in the manual to see and get back. When asked what extent the resident does have use of her dominant hand or either hand? MDS #92 after reviewing the coding options said the MDS was incorrectly coded and should have been marked 2. Limited. At the time of exit the facility had not provided any other evidence as to why section S was coded Other instead of [NAME] Hands c) Resident #61 During an observation on 08/12/19 at 2:41 PM, Resident #61 appeared thin and frail. A nutritional supplement was observed on Resident #61's bedside table. On 08/13/19 at 3:35 PM, a review of Resident #61's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 07/04/19 found that Resident #61's weight had been coded as 124 pounds in section K (nutritional status). A review of Resident #61's weight records on 08/13/19 at 3:36 PM found that the closest weight measurement prior to the ARD of the annual MDS was taken on 07/03/19 and was 121.4 pounds (which, per MDS section K instructions, rounded to 121 pounds). During an interview on 08/14/19 at 8:25 AM, Clinical Reimbursement Coordinator (CRC) #21 stated that the facility's Registered Dietitian (RD) had completed section K for the annual MDS assessment. On 08/14/19 at 8:30 AM, the facility's RD stated that he did not complete section K for Resident #61's annual MDS assessment. However, after reviewing Resident #61's annual MDS, which contained the RD's electronic signature in 25 separate boxes on section K, the RD verified that he had signed off on the section. On 08/14/19 at 8:31 AM, the RD said that section K of the MDS populated automatically. He stated, I normally don't check the weights against PCC (Point Click Care, the electronic medical record utilized by the facility) because it's normally always right. He stated again that he did not do section K of the MDS for the facility's residents. Then, he stated that he did sign off on section K but did not change the populated responses because they were normally right. On 08/14/19 at 8:33 AM, the RD said the 124 pound weight coded in the MDS was probably the 06/12/19 weight of 123.8 pounds. He added that the auto-populated responses on section K had never been wrong. On 08/14/19 at 8:36 AM, the above information was discussed with the facility's Administrator. No further information was provided prior to exit.",2020-09-01
711,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2019-08-14,656,D,0,1,KL5911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident interview, and staff interview the facility failed to develop a person-centered comprehensive care plan to address the resident's medical and physical needs related to mobility. This was true for 1 of 1 residents reviewed for rehabilitation and restorative. This practice had the potential to affect more than a limited number of residents. Resident Identifier #39. Facility census 115. Findings Included: a) Resident (R#39) Review of records, on 08/14/19 at 09:01 AM, revealed pertinent [DIAGNOSES REDACTED]. A cerebral infarction is an inadequate supply of blood to a part of the brain, causing a persistent neurologic deficit in the area affected. According to the Merriam Webster Medical Dictionary, [MEDICAL CONDITION] is muscular weakness or [DIAGNOSES REDACTED] restricted to one side of the body. R#39's [MEDICAL CONDITION] followed a Cerebral Infarction, that affected her left non-dominant side. R#39 was dependent for care. Review of care plan revealed a focus Resident requires assistance for ADL care due to Chronic disease/condition: paralysis to left side, weakness, and contractures. There were no interventions found in the current careplan or in the care plans history that addressed contractures or range of motion for R#39. An interview with occupational therapist (OT#120), on 08/14/19 at 09:14 AM, revealed occupational therapy (OT) has worked with R#39 seven (7) times since being at the facility. OT#120 explained the resident complains of pain so there are limits and restrictions on treatment. The resident chose and was not willing to get out of bed, so we work with her in her bed. A specialized wheelchair was ordered, and the resident refused to use it. We recently picked her up again on case load last week, prior she had therapy from (MONTH) of last year till (MONTH) 2019 then she was out of the facility to the hospital. When she returned from the hospital she was picked back up for services until (MONTH) 2019. Review of orders revealed an order dated 03/11/19 for occupational therapy to evaluate and treat for therapeutic exercises. Review of care plan, on 08/14/19 at 09:44 AM, revealed no interventions in the current care plan or in the history of the care plan that addressed the residents range of motion, contractures, referrals to occupational therapy for evaluations, or mobility needs that might be specific to R#39. An interview with MDS #21 responsible for developing and revising resident's care plans, on 08/14/19 at 09:53 AM, revealed the R#39's careplan was not developed to address range of motion, contractures, or mobility needs. MDS #21 stated she usually always included these areas but agreed R#39's care plan was not developed to include them.",2020-09-01
712,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2019-08-14,756,D,0,1,KL5911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the physician provided a rational for not completing a pharmacist recommended medication gradual dose reduction (GDR). The facility failed to ensure the Director of Nursing or their representative provide their signature acknowledging the pharmacy recommendations. This practice had the potential to affect more than a limited number of residents. Resident Identifier #93. Facility census 115. Findings included: a) Resident (R#93) On 08/13/19 at 04:10 PM, review of medical records revealed a GDR dated 07/08/19 where the pharmacist recommended the discontinuation of the [MEDICATION NAME] (NSAID) due to the resident receiving corticosteroids, [MEDICATION NAME] 10 mg daily, and [MEDICATION NAME] 800 milligrams (mg) every 8 hours (hrs), concomitantly. The resident was also taking Tylenol 150 mg every 12 hours. The pharmacist recommended the discontinuation of the [MEDICATION NAME] and an increase of the frequency of the Tylenol 650 mg every 8 hours instead of every 12 hrs. The rationale for the pharmacist recommendation was the risk of GI (gastric intestinal) bleeding increases significantly when corticosteroids are used in combination with an NSAID (non-aspirin nonsteroidal anti-[MEDICAL CONDITION] drugs). On the GDR form the Physician's responses was to be recorded. There is a box to check to indicate whether the Physician accepts the recommendation and to have it implemented as written, or the option to accept with modifications to the recommendation, or to decline the recommendation with a rationale as to why the recommendation was declined. None of the options were checked in response to the pharmacist recommendations. In the area on the form were a rationale could be given if declined there was written ? Was this for an acute complaint and not stopped signed by the physician. Then an area for the director of nursing (DON) signature, which was blank. At the bottom of the page there was a note Resident is on 1000 mg every 12 hours. No change. With the signature of a registered nurse, RN#41. An interview with RN#41 revealed when she called the physician to notify her of the GDR, the physician did not want any changes and did not give a rational. RN#41 stated that particular physician no longer worked at the facility. According to the Centers for Medicare and Medicaid Services (CMS), State Operation Manual (SOM), appendix PP 'Guidance to Surveyors for Long Term Care Facilities' revealed regulations concerning unnecessary Medications include; Reducing or eliminating the use of the medication may be contraindicated and must be individualized. If the medication is still being used, the clinical record must reflect the rationale for the continued administration of the medication. During an interview on 08/14/19 at 9:13 AM, DON was asked by Surveyor # about the GDR dated 07/08/19 to discontinue [MEDICATION NAME]. The DON agreed that the Physician did not give a rationale for the continued use of the [MEDICATION NAME], and the only order the Physician gave was to increase R#93's [MEDICATION NAME]. Review of a pharmacy consultation report dated 03/12/19 questioning labs for BMP (basic metabolic panel) every ninety-one (91) days was also not signed by the DON acknowledging awareness of the pharmacist's recommendations. The DON confirmed she has not been signing the GDR's or ensuring they were signed by either her or her designee. She agreed this also was a deficient practice.",2020-09-01
713,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2019-08-14,842,D,0,1,KL5911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain medical records on each resident that are complete and accurately documented. The pain assessments were inaccurately recorded for 1 of 1 residents reviewed for the care area of pain. Resident identifier: #101. Facility census: 115. Findings included: a) Resident #101 Resident #101 had [DIAGNOSES REDACTED]. She was receiving the oral medications [MEDICATION NAME] three (3) times a day for pelvic pain and [MEDICATION NAME] 650 mg every six (6) hours for unspecified pain. She was also receiving the topical medication Biofreeze to her right knee twice a pain for pain. She had a physician's orders [REDACTED]. She was to be asked, Are you free of pain or hurting? A Y for yes or a N for no was to be recorded on the Medication Administration Record (MAR). Review of Resident #101's MARs for (MONTH) and (MONTH) demonstrated the daily pain monitoring was recorded as N for 17 occasions in (MONTH) and five (5) occasions thus far in August. Resident #101's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 07/22/19 indicated resident's worst pain was a level three (3) on a scale from one (1) to ten (10), with ten (10) being the worst pain. A pain evaluation performed on 08/13/19 indicated Resident #101's most recent pain level was zero (0). During an interview on 08/13/19 at 3:08 PM, the Director of Nursing (DoN) was informed Resident #101's MARs for (MONTH) and (MONTH) demonstrated the daily pain monitoring was recorded as N for 17 occasions in (MONTH) and five (5) occasions thus far in (MONTH) in response to the question, Are you free of pain or hurting? The DoN confirmed a N, or no, on the MAR indicated the resident was not free of pain. She confirmed if the resident was not in pain, the question should have been answered Y, or yes. During an interview on 08/13/19 at 4:00 PM, the DoN stated the nurses who recorded N on Resident #101's MARs in response to the question, Are you free of pain or hurting?, had done so erroneously. The DoN stated the nurses had thought the question asked if the resident had pain, and recorded N, or no, because the resident had no pain. Licensed Practical Nurse (LPN) #79 was one of the nurses who recorded N on Resident #101's MARs in response to the question, Are you free of pain or hurting? During an interview on 08/13/19 at 4:08 PM, LPN #79 confirmed she thought the question asked if the resident had pain, and recorded N, or no, because the resident had no pain. LPN #79 stated Resident #101 had never reported pain to her. She stated she had never seen Resident #101 demonstrate signs and symptoms of pain. LPN #79 stated the resident was able to propel herself in her wheelchair and went outside in her wheelchair several times a day. During a follow-up interview on 08/14/19 at 8:17 AM, the DoN stated she was performing in-service education to ensure nurses were recording the correct responses on the MARs in response to the question, Are you free of pain or hurting? The DoN stated she had spoken to the nurses who had recorded an N, or no, on Resident #101's MAR in response to the question, Are you free of pain or hurting? The DoN stated all these nurses indicated they misunderstood the question and denied the resident had ever reported pain. No further information was provided prior to the completion of the survey.",2020-09-01
714,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,550,D,0,1,T9WW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, observation, and staff interview, the facility failed to ensure two (2) of three (3) residents reviewed for the care area of dignity were treated with dignity and respect. Resident #31 felt he had to move to a different room because he perceived a nursing staff member did not like him. The facility failed to provide dignity and privacy during a treatment for [REDACTED]. Resident identifiers: #31 and #94. Facility census: 117. Findings include: a) Resident #31 On 08/27/18 at 9:03 AM, the resident was asked whether staff treated him with dignity and respect. The resident replied, (First name of nurse) talked hateful to him. When asked if he reported this he said, Yes, and they moved me over here and kept her over there. He said (first name of the administrator) came and talked to me about it. She is a black lady and he asked me if I was prejudice. I told him I don't think so. She was rude and hateful and I just couldn't get along with her. She was like a drill sergeant. I was in the service too, but I didn't act like that. The incident happened about a month or two ago. The resident said no matter how hard he tried, he just could not get along with her. He really did not want to move to another part of the building, but he felt he had to move to get away from this nurse. He said the girls knew him well on the other hall and he knew them. He had to get used to the new girls when he moved. He also felt his call light was answered quicker on the other side of the building. He wished he could have just stayed where he was. He said he was asked if he wanted to move and he did so only because he could not get along with the one nurse. The resident did deny he was fearful of the nurse. He said it was her attitude and the way she talked that caused him to move. She is a drill sergeant. The resident was admitted to the facility on [DATE]. Review of the census record found the resident was moved from the front hallway to the back hallway on 07/26/18. Review of the facility's reportable allegations of abuse/neglect/misappropriation of property found an allegation reported to the appropriate state authorities on 07/20/18, regarding Resident #31. Licensed Practical Nurse (LPN) #97, previously named by the resident, was reported for, Resident reports that the nurse was upset with him and threw a pillow at him. LPN #97 was suspended pending an investigation. The facility obtained statements from staff working with the resident. Nurse Aide (NA) #81 provided the following statement (typed as written): (name of resident) rung his light, the nurse goes in and ask what does he need, he said he need to be change and would like to have a shower before dinner, the nurse told him he would have to wait because there's other Residents to be take care of beside him, I told him I will be right back and when I got back I heard them arguing. So the nurse walk out of the room, the Resident was crying I told him I would take care of him, he told me that the nurse threw a pillow at him, I ask him why was the curtain pulled he said he told her his back was hurting so she threw a pillow at him and pulled the curtain and walked out. Social Worker (SW) #15 provided a written statement stating she talked to LPN #97 on 07/20/18. LPN #97 said she answered the resident's call light a little after 4:00 p.m. He wanted a shower and she told him he would have to wait until after supper. (Name of LPN) states that she did not have time to care for him and that she did not throw a pillow at him After speaking with the nurse, She left the room, slamming the door. Registered Nurse #76 proved a statement on 07/20/18, she also interviewed LPN #97. According to the statement, LPN #97 denied the allegations. ( . Name of LPN #97) became angry with raised voice when asked about the incident during the interview .she then got up and exited room slamming door behind her. Two additional residents, residing on the unit with Resident #31 at the time of the incident were interviewed. One resident stated, .that sometimes (name of LPN #97) has an attitude, but that she does not have any problems with her. The second resident interviewed did not have any issues. The five day follow up report noted: Substantiated that the nurse did put the pillow on the bed. Upon interviewing the resident, he stated that he did not feel threatened. LPN #97 received an individual performance improvement plan, which she refused to sign. LPN #97 was re-educated on body language and tone of voice and was allowed to return to work. On 08/28/18 at 3:44 PM, the SW #15 said the resident told her he wanted to move, but he did not say it was because of LPN #97. SW #15 provided evidence the resident did receive his shower on 07/20/18, after dinner. On 08/30/18 at 11:12 AM, the administrator said he did talk to the resident and he did ask the resident if he was prejudice. The administrator said the resident requested a room change. He said NA #81 was repeating what the resident told her, not what she saw or overheard. NA #81 could only hear the resident and the nurse arguing. b) Resident #94 On 08/28/18 at 2:33 PM, Licensed Practical Nurse (LPN) #29 failed to close the door to the hallway, did not pull the privacy curtain around the resident's bed, and failed to close the window blinds while providing care to the resident's coccygeal wound. LPN #29 asked Resident #94 to pull his pants down revealing his buttocks. Then he cleansed the wound area and applied a white cream. When asked whether he should have closed the door, the curtain, and window shades, he agreed that he should have. During an interview on 08/28/18 at 3:23 PM, when the Director of Nursing was informed of the observation, she said she would re-educate the nurse. During an interview on 08/28/18 at 4:10 PM, the Administrator was informed about the observation and he stated that was disappointing.",2020-09-01
715,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,580,E,0,1,T9WW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the resident's responsible party when Resident #11 experienced changes in condition prompting changes in insulin dosage and for which a chest x-ray, steroids, and respiratory medications were ordered. Resident #34's responsible party was not notified when a gradual dose reduction failed and medication was reinstituted, when the resident's dose of [MEDICATION NAME] was reduced, or of the results of an x-ray completed after the resident experienced a fall. This was true for two (2) of three (3) residents reviewed for notification of change. Resident identifiers: #11 and #34. Facility census: 117. Findings include: a) Resident #11 Record review found the resident currently lacked capacity to make medical decisions. On 04/01/16, the resident had appointed a Medical Power of Attorney (MPOA) to make health care decisions. Review of the facility's handwritten orders, signed by the physician, found the orders required the writer to note the date of the order, the order, the [DIAGNOSES REDACTED]. On 08/30/18 at 8:51 AM, the following orders were reviewed with the director of nursing (DON): - On 07/20/18, the family nurse practitioner saw the resident for elevated blood sugars and congestion. The following changes in the resident's medications were ordered: -- Discontinue Basaglar kwik pen, 16 units sub Q (subcutaneous), start Basaglar kwik pen 22 units sub Q PM (every evening), Start Humalog 4 units, sub Q, after meals, TID (three times a day.) (Basaglar and Humalog are types of insulin) -- A chest x-ray was ordered-stat (immediately). -- Start [MEDICATION NAME] 40 mg, IM (intra muscular) now then start [MEDICATION NAME] Dose pack in the AM. -- [MEDICATION NAME] every 6 hours, unit dose, times 14 days. -- [MEDICATION NAME] pearls, 100 milligrams, by mouth, BID (two times a day) for 14 days. The DON reviewed the handwritten orders, the nurses' notes, the change in condition report, and was unable to find verification the MPOA was notified of the changes in the resident's condition. b) Resident #34 A telephone interview with the resident's responsible party on 08/27/18 at 3:52 PM, found the responsible party did not always believe she was notified of changes in condition. She said she was never notified of the results of an X-ray regarding her mother's hand. She said, I guess if it was broken they would have called me by now. She said when she came to visit she would find out medications had been changed without her notification. (On 12/23/17, the resident's physician determined the resident demonstrates incapacity to make medical decisions.) Review of the facility's handwritten orders, signed by the physician, found the order required the writer to note the date of the order, the order, the [DIAGNOSES REDACTED]. Review of the following orders found no verification the responsible party was notified of changes in condition: - 06/28/18, a new order for [MEDICATION NAME] 20 milligrams (mg) PO (by mouth), due to a failed gradual dose reduction, major [MEDICAL CONDITION]. Start [MEDICATION NAME] 20 mg, PO, every other day for 2 weeks then stop. - 05/29/18, a new order to discontinue [MEDICATION NAME] sprinkles 250 mg, PO BID (two times a day) Start [MEDICATION NAME] sprinkles, 125 mg PO BID. - On 05/29/18, the physician ordered an x-ray of the resident's left wrist after a fall. The nurses' notes indicated the responsible party was notified of the fall, but there was no evidence the responsible party was notified of the results of the x-ray which indicated the wrist was not broken. On 08/29/18 at 8:11 AM, the DON confirmed she reviewed the orders, nurses' notes, and change in condition reports and she was unable to verify the responsible party was notified of the changes in the resident's condition. She stated nurses should document on the order when the responsible party was notified and the date of notification.",2020-09-01
716,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,600,D,0,1,T9WW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to ensure Resident #21 was free from neglect. On 08/23/18, Resident #21, who was assessed as requiring the use of a sit to stand lift for transfers, fell in the shower room when she attempted to stand while being dressed by a nurse aide (NA) without benefit of a lift. This was true for one (1) of five (5) residents reviewed for the care area of abuse and neglect during the Long Term Care Survey Process. Resident Identifier: #21. Facility Census: 117. Findings Include: a) Resident #21 During an interview at 2:42 p.m. on 08/28/18, the resident said she had fallen in the shower room on 08/23/18. According to the resident, Nurse Aide (NA) #41 had dried her off and had her pants and her brief pulled up to her knees. When she got to the assist bar and used the bar to help her stand up, she said, My hands had lotion on them and when I stood up to the assist bar I fell over like a tree. She added that NA #41 got two (2) other NAs (NA #38 and NA #67) to help get her back in her wheelchair. Resident #21 stated staff did not use a lift at any point during her shower or after her fall. A review of Resident #21's medical record at 3:00 p.m. on 08/28/18 found the record void of any documentation related to this fall. The record did however, contain a lift assessment dated [DATE] which indicated the resident was to be transferred via a sit to stand lift. During an interview at 4:07 p.m. on 08/28/18, the Director of Nursing (DON) said she was not aware of the resident's fall and would have to investigate to see what had happened. The information provided by Resident #21 during the interview, including that a lift was not used to transfer her, was shared with the DON. The DON stated if the resident's lift assessment indicated she needed a sit to stand lift, then staff should have used a lift. She also commented that if staff were using a lift, there would need to be two (2) staff members present during the transfer. An additional interview at 8:14 a.m. on 08/29/18, the DON confirmed there was no documentation in the resident's medical record regarding the resident's fall on 08/23/18. She stated the nurse aide told a nurse, but when the nurse went to talk to the resident about it, the resident told the nurse she did not fall. She stated that NA #41 did not perceive the incident as a fall because she let the resident slide down her leg so she did not think that it was a fall. The DON indicated that she was doing some education with the staff about what a fall is. When asked why the staff did not use a sit to stand lift the DON stated, I do not know for sure why she did not use the lift. An interview with the Nursing Home Administrator (NHA) at 5:23 p.m. on 08/29/18 revealed if the resident's lift assessment indicated the resident was to be transferred with a sit to stand lift that the NAs should have been using the lift on her during the shower process. He agreed that this was neglectful on the part of the N[NAME]",2020-09-01
717,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,609,D,0,1,T9WW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to ensure an allegation of neglect involving Resident #21 was reported to the appropriate State agencies within 24 hours. Resident #21 fell on [DATE] while in the shower room while being showered by one (1) nurse aide (NA). The resident fell when the NA did not utilize a sit to stand life as assessed on the resident's lift assessment. This was true for one (1) of five (5) residents reviewed for the care area of abuse and neglect during the Long Term Care Survey Process. Resident Identifier: #21. Facility Census: 117. Findings Include: a) Resident #21 During an interview at 2:42 p.m. on 08/28/18, the resident said she had fallen in the shower room on 08/23/18. Resident #21 indicated that she was in the shower room with Nurse Aide (NA) #41. The resident stated when used the assist bar to help her stand, My hands had lotion on them and when I stood up to the assist bar I fell over like a tree. She indicated that NA #41 got two (2) other NAs (NAs #8 and #67) to help get her back in her wheelchair. According to the resident, the staff did not use a lift at any point during her shower or after her fall. A review of Resident #21's medical record at 3:00 p.m. on 08/28/18 found the resident's medical record contained a lift assessment dated [DATE], which indicated the resident was to be transferred via a sit to stand lift. An interview with the Director of Nursing (DON) 04:07 p.m. on 08/28/18 revealed she was not aware of the fall and would have to investigate it and see what happened. The DON was made aware that the resident had reported during her interview that staff did not use a lift to transfer her. The DON said if the resident's lift assessment identified she needed a sit to stand lift, then staff should have used a lift on her and to do that, two (2) staff members would be needed to transfer her. An interview with the Nursing Home Administrator (NHA) at 5:23 p.m. on 08/29/18 revealed if the resident's lift assessment indicated the resident was to be transferred with a sit to stand lift, the NAs should have been using the lift on her during the shower process. He agreed that this neglectful on the part of the N[NAME] He was advised the DON was made aware of this allegation of neglect at 4:07 p.m. on 08/28/18. He indicated that this had not been reported and should have been reported as neglect because the nurse aide should have been using the sit to stand lift as directed by the resident's care plan and lift assessment.",2020-09-01
718,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,641,D,0,1,T9WW11,"**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 the minimum data set (MDS) assessment for one (1) of four (4) residents reviewed for the care area of dental care, had an accurate and complete minimum data set (MDS) that reflected the current dental status of the resident. Resident identifier: #65. Facility census: 117. Findings included: a) Resident #65 During an interview with the resident on 08/27/18 at 9:23 AM, he said he had no teeth and would like to get some false teeth. He also said his gums got sore at times. Review of the last full Minimum Data Set (MDS), a significant change MDS with an assessment reference date (ARD) of 01/14/18, found the assessor had coded the resident as having obvious or likely cavities or broken natural teeth. The facility care planned the resident for being at risk for oral health or dental care problems as evidenced by broken, loose and carious teeth. At 11:05 AM on 08/28/18, Social Worker (SW) #15, confirmed the resident had never seen a dentist since his admission to the facility on [DATE]. Nursing assessments completed on 04/16/18 and 01/16/18 noted the resident had no natural teeth and no dentures. Observation of the resident's oral cavity on 08/28/18 at 11:29 AM, with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) found the resident did not have any natural teeth. During the observation, the resident said he had dentures at one time, but he thought he left them at his mothers' house. The DON confirmed the MDS completed on 01/14/18 was incorrect.",2020-09-01
719,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,656,E,0,1,T9WW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, observations, medical record review, facility policy review, and staff interview, the facility failed to develop and implement individualized care plans for five (5) of twenty-six (26) residents whose care plans were reviewed. Resident #73's care plan did not address care of her catheter drainage bag, Resident #21's care plan did not identify how much staff assistance the resident needed for Activities of Daily Living (ADL), Resident #67's care plan for no blood pressures (B/P) in the resident's left arm was not implemented, Resident #65's care plan did not accurately address the resident's dental/oral care needs, and Resident #93's care plan did not address familial issues. Facility census: 117. Resident identifiers: #73, #21, #67, #65, and #93. Findings included: a) Resident #73 During an interview on 08/27/18 at 3:39 PM, it was noted that Resident #73 had a Foley Catheter bag that could be seen under her dress. When asked about her catheter, she said she empties it herself. She was asked if the nurses help her hang the catheter bag to the side of her bed at night. She said, No I don't do that it stays on my belly. She was asked again if her Foley Catheter bag was hung on bedside at night or changed to a bedside drainage bag at night. She again stated no. During an interview on 08/28/18 at 12:59 PM, Licensed Practical Nurse (LPN) #2, the Assistant Director of Nursing (ADON), and LPN #20 Unit Manager, were asked if the staff assisted Resident #73 with the care of her Foley Catheter. All three (3) of the staff stated the resident hung the bag on the side of the bed at night. During an observation on 08/28/18 at 1:10 PM, Resident # 73 emptied her Foley Catheter into the toilet wearing gloves. LPN #20 was present as well. Resident #73 was asked again if she hung the bag on the side of the bed at night and she said, No, it's on my belly at night. On 08/28/18 at 1:30 PM, the ADON and Administrator were informed about finding. The Administrator stated that the resident needed to be re-educated. ADON and LPN #20 stated that staff would also be re-educated, and they would put it on the treatment record starting that day for her Foley catheter bag to be hung at bedside at night. The Facility's Policy, Catheter: Indwelling Urinary-Care of with an Effective Date: 06/01/96 Revision Date: 01/02/14, directed, Keep the drainage bag below the level of the patient's bladder. A review of the resident's care plan found that the care of the catheter bag at bed time was not addressed. b) Resident #21 A review of Resident #21's care plan on 08/28/18 at 3:00 p.m. found a focus statement, (Resident #21's first name) requires assistance for ADL care (bathing, grooming, dressing, bed mobility, transfer, locomotion, toileting) due to HX (history of)[MEDICAL CONDITION]([MEDICAL CONDITION] or stroke) affecting the right side. This focus statement was initiated on 03/06/18 with a revision date of 06/05/18. The goal associated with this focus statement was, (First name of Resident #21) ADL care needs will be met in order to maintain the highest practicable level of functioning and physical well being X 90 days. This goal was initiated on 03/06/18 with a target date of 09/03/18. The interventions associated with this focus statement and goal included: Bathing: Total assist of 1 - 2 person. Bed Mobility: Extensive assist of 1 - 2 person. Dressing: Extensive assist of 1 - 2 person. Grooming: Extensive assist of 1 - 2 person. Toileting: Extensive assist of 1 - 2 person. Transfers: Extensive assist of 1 - 2 person. (Sit to stand Lift) An interview with the Director of Nursing (DON) on 08/28/18 at 4:07 p.m. confirmed the resident's care plan was not individualized to identify whether Resident #21 needed a one (1) or two (2) person assist. She agreed the Nurse Aides were not able to assess residents and the care plan needed to be specific in how many people needed to assist Resident #21 with her ADLs. c) Resident #67 A review of Resident #67's care plan at 11:00 a.m. on 08/29/18 found a focus statement initiated on 03/09/18: (First Name of Resident #67) is at risk for impaired renal function and is at risk for complications related to [MEDICAL TREATMENT]. The goals associated with this focus statement were, (First Name of Resident #67) will not experience any complications related to chronic insufficiency requiring hospitalization writhing next review. Initiated on 03/09/18 Target Date: 10/16/18. (First name of Resident #67) will avoid fluid overload requiring hospitalization within next review. Initiate on 03/09/18 Target Date: 10/16/2018. The interventions associated with this focus statement and goals included: Monitor [MEDICAL TREATMENT] access for +bruit/+thrill q shift and prn. No B/P or Sticks left arm. ( .for positive bruit/positive thrill every shift and as needed. No Blood Pressure or ) This intervention was initiated on 03/09/18. Further review of Resident #67's medical record found on the following dates and times staff documented they obtained Resident #67's blood pressure in her left arm: 03/09/18 at 11:16 a.m. 03/19/18 at 11:00 a.m. 03/24/18 at 10:54 a.m. 03/25/18 at 2:51 p.m. 04/01/18 at 2:42 p.m. 04/10/18 at 4:55 p.m. 04/28/15 at 9:56 a.m. 05/04/18 at 11:09 a.m. 05/16/18 at 3:01 p.m. 05/20/18 at 2:50 a.m. 05/20/18 at 4:23 a.m. 06/04/18 at 12:36 a.m. 07/20/18 at 10:12 p.m. 07/21/18 at 4:38 a.m. 07/22/18 at 12:45 a.m. 07/30/18 at 4:18 p.m. and 08/23/18 at 10:18 a.m. An interview with the Director of Nursing (DON) on 08/29/18 at 2:02 p.m. confirmed the nursing staff documented they obtained the resident's blood pressure in her left arm. She confirmed the resident's blood pressure should not be obtained in the left arm because of her [MEDICAL TREATMENT] access being in her left arm. d) Resident #65 During an interview with the resident on 08/27/18 at 9:23 AM, he said he had no natural teeth and would like to get some false teeth. He also said his gums get sore at times. Review of the last full Minimum Data Set (MDS), a significant change MDS with an assessment reference date (ARD) of 01/14/18, found the facility coded the resident has having obvious or likely cavity or broken natural teeth. The facility care planned the resident for being at risk for oral health or dental care problems as evidenced by broken, loose and carious teeth. The goal associated with the problem was: Resident will maintain intact oral mucous membranes as evidence by the absence of discomfort, gum inflammation/infection, oral [MEDICAL CONDITION] by next review. Interventions included: Brush teeth/gums with a soft toothbrush daily. Obtain dental consult as ordered. At 11:05 AM on 08/28/18, the Social Worker confirmed the resident had never seen a dentist since his admission to the facility on [DATE]. Nursing assessments completed on 04/16/18 and 01/16/18 noted the resident had no natural teeth and no dentures. Observation of the resident's oral cavity on 08/28/18 at 11:29 AM with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), found the resident did not have any natural teeth. During the observation, the resident said he had dentures at one time, but he thought he left his dentures at his mother's house. The DON confirmed the care plan was incorrect as the resident had no natural teeth. e) Resident #93 Record review found the resident was only allowed supervised visits with his wife. On 11/19/15, the court appointed the Department of Health and Human Resources (DHHR) as the resident's guardian and the Sheriff as the resident's Conservator. The DHHR sent a letter to the resident's wife on 06/07/18, with a copy to the facility noting, .You were given a visitation guideline list in a letter dated 08/26/16, with criteria that needed to be followed during the supervised visits with (name of resident). During recent visits the criteria have not been followed concerning no derogatory statements made to client, encouraging non-compliance with medical care, and no disruption to the facility or staff during the visits such as name calling, yelling or other disruptive behavior .Per conversation on 06/05/18, you may call (name of Resident) 4 times weekly. At 11:00 a.m. on 08/27/18, the worker at the local DHHR was contacted by telephone regarding the resident. The local worker said the Department was currently in the process of restricting all visits due to the wife's inappropriate behavior. The DHHR had instructed the facility to allow only 4 telephone calls a week and the facility was to try to write all the calls down. Review of the nursing notes found the facility was documenting the telephone calls as instructed. On several occasions the resident's wife was told she had already made the allowed 4 telephone calls a week. At 7:57 AM on 08/28/18, the director of nursing and assistant director of nursing were interviewed. They were both aware of the stipulations from the DHHR. At 4:48 PM on 08/29/18, Social Worker (SW) #15 related one of the resident's sons, as well as a brother and 2 sisters, were allowed to visit the resident. She said, Only the wife and 1 son can't visit. Review of the resident's current plan of care with SW #15 found no information relating to the supervised visits and the limited telephone calls. A current care plan problem was: (Name of Resident) lacks decision making capacity and APS (Adult Protective Services) is legal guardian . The goal is the resident/guardian shall participate in decisions regarding medical care and treatment thru review period. Interventions included; Provide emotional support to resident/family. SW #15 was asked how the facility would provide support to the family when the facility did not supervise visits and only connected the telephone calls to the resident's room. Also, the facility corresponded with the DHHR, not the resident's family. The care plan did not entail which family members could visit and which family members could not visit without the supervision of the DHHR. SW #15 did not respond to the questions. SW #15 did confirm the care plan did not include the stipulation of the visits, who was allowed to visit with or without supervision, and the limited telephone calls.",2020-09-01
720,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,657,E,0,1,T9WW11,"**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 revision of the comprehensive care plan for five (5) of twenty-six (26) residents reviewed during the Long-Term Care Survey Process. The facility failed to revise the care plan in the area of [MEDICAL CONDITION] medications for Resident #72. The facility failed to ensure the comprehensive care plan was revised by the interdisciplinary team with participation by the resident after the quarterly Minimum Data Set (MDS) assessment for Resident #59. The facility failed to revise the comprehensive care plans in the area of nutrition for Resident #101 and Resident #114. The facility failed to revise the comprehensive care plan in the area of contracture prevention for Resident #65. Resident identifiers: #72, #59, #101, #114, and #65. Facility census: 117. Findings include: a) Resident #72 Review of Resident #72's physician orders [REDACTED]. Resident #72's comprehensive care plan contained the focus, (Resident's name) is at risk for complications related to the use of [MEDICAL CONDITION] drugs. The interventions included administering Trazadone and monitoring for side-effects from the medication. During an interview on 08/28/18 at 4:17 PM, Coordinator-Clinical Reimbursement (C-CR) #25 verified Resident #72's comprehensive care plan contained an intervention relating to Trazadone, although the medication had been discontinued on 01/08/18. C-CR #25 stated Resident #72's comprehensive care plan would be revised to remove the discontinued medication Trazadone. b) Resident #59 During an interview on 08/27/18 at 3:22 PM, Resident #59 stated she had attended a meeting to discuss her plan of care after she was admitted to the facility. However, she stated she had not been to a care plan meeting since that time. Review of Resident #59's medical records revealed an interdisciplinary care plan conference had been held on 04/09/18. The medical records did not contain evidence an interdisciplinary care plan conference had been held after that date. During an interview on 08/29/18 at 3:04 PM, Specialist-Social Services (S-SS) #15 verified Resident #59's most recent interdisciplinary care plan conference had been held on 04/09/18. S-SS #15 stated interdisciplinary care plan conferences were usually held after quarterly MDS assessments. Resident #59's most recent quarterly MDS had an assessment reference date (ARD) of 07/13/18. S-SS #15 stated she would schedule an interdisciplinary care plan conference for Resident #59. A Social Service note written on 8/29/2018 at 6:52 PM stated a care conference was scheduled with Resident #59 on 09/07/18. c) Resident #101 Resident #101 had a [DIAGNOSES REDACTED]. She had been receiving nutrition through a percutaneous endoscopic gastrostomy (PEG) tube. On 08/24/18, Resident #101 pulled out the PEG tube. Both the resident and her representative declined to have the PEG tube reinserted. Resident #101's diet was changed to a pureed diet with honey thickened liquids. Upon review, Resident #101's comprehensive care plan did not contain a focus related to her nutritional status. During an interview on 08/29/18 at 11:17 AM, Coordinator-Clinical Reimbursement (C-CR) #25 stated Resident #101's nutritional focus had been resolved on 08/28/18 due to discontinuation of her PEG tube. However, a new focus reflecting Resident #101's current nutritional needs had not been initiated. C-CR #25 provided evidence that the focus, Resident has an enteral feeding tube to meet nutritional needs, dysphagia was resolved on 08/28/18. C-CR #25 stated Resident #101's comprehensive care plan would be revised to include an updated focus regarding nutrition. d) Resident #114 Resident #114 had a [DIAGNOSES REDACTED]. Record review found Resident #114's comprehensive care plan did not contain a focus related to nutritional status. During an interview on 08/28/18 at 4:26 PM, Coordinator-Clinical Reimbursement (C-CR) #25 stated Resident #114's nutritional focus had been resolved due to the resident's inability to meet the stated goals of having stable body weight and averaging an intake of at least 50% of meals. However, a new nutritional focus with realistic goals had not been initiated. C-CR #25 provided evidence that the focus, Resident at nutrition risk due to poor PO (oral) intake, e) Resident #65 Observation of the resident on 08/27/18 at 11:18 AM, found the resident was up in his room in the wheelchair. His nursing assistant was applying a knee brace on his right knee. Review of the resident's current care plan found the following problem: Restorative Range of Motion: Patient demonstrates loss of range of motion in RLE (right lower extremity) Cognitive loss/dementia, Functional deterioration. The goal associated with the problem was: Will participate in Restorative RLE exercises, and decrease stiffness in RT (right) knee. Interventions included: PROM (Passive Range of Motion) RLE exercises, gentle knee flexion & extension with gentle stretches per his tolerance 1 - 2 reps (repetitions) week to his tolerance 6 days a week. (typed as written). At 12:10 p.m. on 08/28/18, the director of nursing said the resident was to have the brace, it was ordered by therapy. The DON provided a copy of an in-service education dated 08/15/18 directing staff to apply a right knee brace while the resident was up in his tilt-in-space chair, as tolerated by the resident. At 12:20 PM on 08/28/18, Physical Therapist #126 verified therapy had directed the resident to have a right knee brace and had provided the education for use on 08/15/18. At 12:30 PM on 08/28/18, the DON confirmed the resident's care plan was not updated to include the knee brace for contracture prevention.",2020-09-01
721,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,684,G,0,1,T9WW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview, the facility failed to ensure residents received needed care and services to meet each resident's physical, mental, and psychosocial needs. For Resident #64, the facility failed to promptly notify Resident #64's attending physician of chest x-ray results that indicated the resident had pneumonia. The resident was not started on intravenous (IV) antibiotics until almost a week later. The resident was upset by this and felt as if she was being neglected by the facility and felt she would never get better. Resident #64 voiced feelings of anxiousness and worry on 08/28/18 when there was a delay in starting her antibiotic once the physician had reviewed the results and ordered the antibiotics be started. The resident's feelings of neglect, anxiousness and worry resulted in Resident #64 suffering psychosocial harm. For Resident #101, staff failed follow a physician's orders [REDACTED]. These failures affected two (2) of twenty-six (26) sampled residents during the Long-Term Care Survey Process. Resident Identifiers: #64 and #101. Facility Census: 117. Findings Include: a) Resident #64 An interview with Resident #64 at 11:00 a.m. on 08/28/18 found the previous week, the physician had ordered a chest x-ray for the resident because she had wheezing in her lungs. She reported that a couple days ago (First name of Nurse Practitioner) told her that her chest x-ray was clear. She said that the night before last she woke up about 12:15 a.m. and was freezing like she had a fever and they had to put the heat on 85 degrees to get her warm. She stated early this morning they brought an IV pump into her room and told her that she was going to be started on an IV antibiotic because her chest x-ray she had done last week showed she had pneumonia. She stated they told her the attending physician reviewed the x-ray report last night and ordered the IV antibiotics. She stated, I am upset because it has been almost a week since they got the x-ray report and (First name of Nurse Practitioner) told me it was clear. She indicated that she felt she was being neglected and she was very worried about her health and wanted to get well. A review of Resident #64's medical record found a physician's orders [REDACTED]. A review of the record found the chest x-ray results for 08/22/18. The conclusion on the radiologist's report on 08/22/18 at 12:04 p.m. was, Slight right lower lobe infiltrate new since 08/15/18. Mild cardiomegaly. The results were signed by the attending physician on 08/27/18 and he wrote an order on the X-ray report, [MEDICATION NAME] 750 mg IV q day for 7 days. An interview with the Nurse Practitioner on 08/28/18 at 1:10 p.m. revealed she had not reviewed the resident's x-ray report because she was on vacation last week. She indicated she did not speak to the resident about her x-ray report and that perhaps the resident had her confused with someone else. An interview with the Director of Nursing (DON) at 1:21 p.m. on 08/28/18 confirmed the physician had not been notified of the x-ray report in a timely manner. She stated, I have no explanation for the delay in notification. An additional interview with Resident #64 at 1:31 p.m. on 08/28/18 revealed she did not feel well. She stated that she had no energy and she coughed, but could not get anything up. She indicated that she was very aggravated with the facility right now because she has a port which they could use to give her the antibiotics and she had been waiting since early that morning to get her antibiotic started. She stated, I don't know what is taking them so long, they can use my port. She indicated, she had anxiety about not getting her antibiotics started that morning and that the delay was adding more worry on top of the worry already caused by the delay in treatment. The resident's feeling of neglect, anxiety, and worry resulted in the resident suffering psychosocial harm. An interview with the DON at 1:53 p.m. on 08/28/18 found that Resident #64's antibiotic had arrived sometime in the early morning hours. She indicated that any Registered Nurse (RN) could start the antibiotic and she would have someone get it started. The DON indicated there were five (5) RNs working that morning and any of them could have started the antibiotic. Despite the antibiotic having arrived from the pharmacy early that morning and staff telling Resident #12 they were going to be starting it that morning, it was not started until 2:00 p.m. on 08/28/18. (The attending physician did order a repeat chest x ray on 08/28/18. The results of this x ray were reviewed and found the resident's pneumonia was clear. Based on these results the attending physician discontinued the residents IV antibiotics after only one dose.) b) Resident #101 Review of Resident #101's medical records revealed a Change in Condition Evaluation dated 08/21/18 at 3:06 AM reporting a red, bumpy, itchy rash on the resident's chest and shoulders. The rash was reported as starting on the morning of 08/19/18. The rash was reported to the physician on 08/21/2018 at 6:00 AM. A telephone order was obtained from the physician on 08/21/18 at 6:44 PM for [MEDICATION NAME] to affected area BID (twice a day) and PRN (as needed) d/t (due to) pruritis (itching). During an interview on 08/29/18 at 11:00 AM, the Center Nurse Executive (CNE) stated Change in Condition Evaluations were typically documented at the time the change in condition was discovered. She stated she would attempt to determine the reason Resident #101's rash was identified on 08/19/18, but not reported until 08/21/18. On 08/29/18 at 12:42 PM, the CNE reported Resident #101's rash was identified on 08/19/18 by a nurse who did not have computer access to Change in Condition Evaluations. The Change in Condition Evaluation was documented on 08/21/18 by another nurse who did have computer access to the form. The CNE stated she would look for information as to whether the physician was notified regarding Resident #101's rash before 08/21/18. On 08/29/18 at 2:25 PM, the CNE stated she had been unable to locate documentation that the physician was notified about Resident #101's rash before 08/21/18. Review of Resident #101's Treatment Administration Record (TAR) found the task to apply [MEDICATION NAME] twice a day and as needed to the resident's rash, as ordered by the physician on 08/21/18. The task was scheduled to be performed once a day on the 7:00 AM to 7:00 PM shift and once a day on the 7:00 PM to 7:00 AM shift. However, only the following dates and times were initialed by the nurse, indicating the medication had been applied: - 08/21/18 on the 7:00 PM to 7:00 AM shift - 08/22/18 on the 7:00 AM to 7:00 PM shift - 08/27/18 on the 7:00 AM to 7:00 PM shift - 08/28/18 on the 7:00 AM to 7:00 PM shift During an interview on 08/29/18 at 11:03 AM, the Nurse Unit Manager, Licensed Practical Nurse (LPN) #20, confirmed the TAR documented [MEDICATION NAME] ointment had only been applied four (4) times since ordered on [DATE]. She stated she thought the order for Resident #101's [MEDICATION NAME] ointment was only as needed, rather than twice a day and as needed. She stated other nurses may have also thought the [MEDICATION NAME] ointment order was for the medication only to be applied as needed, rather than twice a day and as needed. LPN #20 stated she would re-write the order on the TAR to clarify [MEDICATION NAME] ointment should be applied twice a day and as needed, as ordered by the physician. On 08/30/18 at 12:17 PM, the Administrator was notified about the facility's failure to document and report to the physician Resident #101's rash at the time the rash was identified on 08/19/18. The Administrator was also notified about the facility's failure to apply [MEDICATION NAME] ointment twice a day as ordered by the physician. The Administrator had no further information regarding these matters.",2020-09-01
722,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,689,D,0,1,T9WW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to ensure Resident #21 received adequate supervision and assistance devices. The resident, who was assessed to require the use of a sit to stand lift for transfers, fell in the shower room when she attempted to stand holding on to an assist bar while a nurse aide (NA) pulled up her brief and pant leg. Additionally, according to the resident, she was unable to hold on to the assist bar because she had lotion on her hands. The lift was not used during the entire shower process and only one NA was assisting the resident. This was true for one (1) of one (1) residents reviewed for the care area of accidents during the Long-Term Care Survey Process. Resident Identifier: #21. Facility Census: 117. Findings Included: a) Resident #21 An interview with Resident #21 at 2:42 p.m. on 08/28/18 found she had fallen in the shower room on 08/23/18. According to the resident, NA #41 had dried her off and had her pants and her brief pulled up to her knees. She stated that when she attempted to stand using the assist bar, My hands had lotion on them and when I stood up to the assist bar I fell over like a tree. She added that NA #41 got two (2) other NAs (NA #38 and NA #67) to help get her back in her wheelchair, but they did not use a lift at any point during her shower or after her fall. A review of Resident #21's medical record at 3:00 p.m. on 08/28/18 found a lift assessment dated [DATE] which indicated the resident was to be transferred via a sit to stand lift. During an interview at 4:07 p.m. on 08/28/18, the Director of Nursing (DON) stated she was not aware of the fall and she would have to investigate to see what had happened. When informed that the resident had reported staff did not use a lift to transfer her, the DON indicated if her lift assessment indicated she needed a sit to stand lift they should have used a lift for her. She also commented that if they were using a lift, they would have to have two (2) people to transfer her. At 8:14 a.m. on 08/29/18, the DON reported the nurse aide told a nurse, but when the nurse went to talk to the resident about it, she told the nurse she did not fall. She stated that NA #41 did not perceive the incident as a fall because she let the resident slide down her leg. The DON indicated that she was doing some education with the staff about what should be considered a fall. When asked why the staff did not use a sit to stand lift the DON stated, I do not know for sure why she did not use the lift.",2020-09-01
723,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,690,E,0,1,T9WW11,"Based on observation, resident interview, staff interview, and review of a facility policy, the facility failed to ensure Resident #73's urinary drainage bag was maintained at a level below her bladder to lessen the potential for the resident to develope a urinary tract infection. This was true for one (1) of one (1) reviewed for catheter care. Identified Resident: #73. Facility census: 117. Findings included: a) Resident #73 During an interview on 08/27/18 at 3:39 PM, it was noted that Resident #73 had a Foley catheter bag that could be seen under her dress. When asked if the nurses helped her hang the catheter bag to the side of her bed at night, she replied, No, I don't do that, it stays on my belly. When asked a second time about whether her catheter bag was hung on her bedside at night or changed to a bedside drainage bag at night, she again stated no. During an interview on 08/28/18 at 12:59 PM, Licensed Practical Nurse (LPN) #2, Assistant Director of Nursing (ADON) and LPN #20 Unit Manager, were asked if the staff assisted Resident #73 with the care of her catheter bag. All three (3) stated the resident hung the bag on the side of her bed at night. During an observation on 08/28/18 at 1:10 PM, in the presence of LPN #20, Resident #73 emptied her catheter bag into the toilet wearing gloves. Resident #73 was asked again if she hung the bag on the side of the bed at night and she said, No, it's on my belly at night. On 08/28/18 at 1:30 PM, the ADON and Administrator were informed about finding. The Administrator stated that the resident needed to be re-educated. The ADON and LPN #20 stated that the staff would be re-educated, and they would put it on the treatment record starting today that her catheter bag was to be hung at bedside at night. The Facility's Policy, Catheter: Indwelling Urinary-Care of Effective Date: 06/01/96 Revision Date: 01/02/14, included, Keep the drainage bag below the level of the patient's bladder. (Note: By keeping the bag on her belly at night, it inhibited the drainage of urine from her bladder and could allow urine to flow back into her bladder, which could cause or contribute to a urinary tract infection.)",2020-09-01
724,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,698,E,0,1,T9WW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to ensure the [MEDICAL TREATMENT] Communication Record was maintained in Resident #67's medical record for each time she went to [MEDICAL TREATMENT]. The facility also failed to complete the post [MEDICAL TREATMENT] section of the [MEDICAL TREATMENT] Communication Record on the forms that were returned to the facility. Additionally, the facility staff had documented that the resident's blood pressures were taken in the resident's left arm which is a restricted limb related to her [MEDICAL TREATMENT] access. This was true for one (1) of one (1) resident reviewed for the care area of [MEDICAL TREATMENT] during the Long-Term Care Survey. Resident Identifier: #67. Facility Census: 117. Findings included: a) Resident #67 1. Facility Policy A review of the facility's policy titled, [MEDICAL TREATMENT] Communication and Documentation on 08/29/18 at 10:00 a.m., found the following Practice Standards: 1. Prior to a patient leaving the center for outpatient [MEDICAL TREATMENT] treatment, a licensed nurse will complete the top portion of the [MEDICAL TREATMENT] Communication Record or the state required form and send with the patient to his/her out patient [MEDICAL TREATMENT] center visit. 2. Following completion of the out-patient [MEDICAL TREATMENT] treatment, the [MEDICAL TREATMENT] nurse should complete the form and return it or other communication to the Center with the patient. 3. Upon return of the patient to the center, a licensed nurse will: 3.1 Review the [MEDICAL TREATMENT] center communication; 3.2 Evaluate/observe the patient; and 3.3 Document the evaluation/observation on the [MEDICAL TREATMENT] Communication Record or state required form. 4. Notify the [MEDICAL TREATMENT] center if the form is not returned with the patient and ask that it be faxed to the center. 4.1 Document notification of [MEDICAL TREATMENT] center regarding return for form or other communication. 5. Maintain the [MEDICAL TREATMENT] Communication Record or state for in the patient's medical record. 2. Maintaining the [MEDICAL TREATMENT] Communication Record in the Residents Medical Record. Review of Resident #67's record at 11:00 a.m. on 08/29/18 found she was scheduled for [MEDICAL TREATMENT] on Tuesday, Thursdays, and Saturdays. Further review of the record found no [MEDICAL TREATMENT] communication sheets for the following days when Resident #67 went to [MEDICAL TREATMENT]: 06/02/18, 06/06/18, 06/07/18, 06/09/18, 06/12/18, 06/16/18, 06/21/18, 06/23/18, 06/28/18, 07/03/18, 07/05/18, 07/12/18, 07/19/18, 07/21/18, 07/26/18, 07/28/18, 07/31/18, 08/02/18, 08/04/18, 08/07/18, 08/23/18 and 08/25/18. An interview with the Director of Nursing (DON) on 08/29/18 at 11:23 a.m. confirmed there was no [MEDICAL TREATMENT] Communication Record for the identified dates. She agreed their policy indicated that these would be maintained in the record and they were not there. 3. Completion of the [MEDICAL TREATMENT] Communication Record A review of Resident #67's medical record at 11:00 a.m. on 08/29/18 found a [MEDICAL TREATMENT] Communication Record for the following dates: 06/14/18, 06/19/18, 06/26/18, 06/30/18, 07/07/18, 07/10/18, 07/14/18, 07/17/18, 07/24/18, 08/11/18, 08/14/18, 08/16/18, 08/19/18, 08/21/18, and 08/28/18. The forms were reviewed and found that the last section, which was to be completed by the licensed nurse upon the resident's return to the facility, was not completed on any of the identified forms. An interview with the DON at 11:23 a.m. on 08/29/18 confirmed the resident's [MEDICAL TREATMENT] Records for the above-mentioned dates were not completed in their entirety at directed by the facility's policy. 4. Obtaining Blood Pressure in Restricted Limb A review of Resident #67's medical record at 11:00 a.m. on 08/29/18 found a physician's orders [REDACTED]. Further review of Resident #67's medical record found on the following dates and times, staff documented they obtained Resident #67's blood pressure in her left arm: 03/09/18 at 11:16 a.m. 03/19/18 at 11:00 a.m. 03/24/18 at 10:54 a.m. 03/25/18 at 2:51 p.m. 04/01/18 at 2:42 p.m. 04/10/18 at 4:55 p.m. 04/28/15 at 9:56 a.m. 05/04/18 at 11:09 a.m. 05/16/18 at 3:01 p.m. 05/20/18 at 2:50 a.m. 05/20/18 at 4:23 a.m. 06/04/18 at 12:36 a.m. 07/20/18 at 10:12 p.m. 07/21/18 at 4:38 a.m. 07/22/18 at 12:45 a.m. 07/30/18 at 4:18 p.m. and 08/23/18 at 10:18 a.m. An interview with the Director of Nursing (DON) on 08/29/18 at 2:02 p.m. confirmed the nursing staff documented they obtained the resident's blood pressure in her left arm. She confirmed the resident's blood pressure should not be obtained in the left arm because of her [MEDICAL TREATMENT] access being in her left arm.",2020-09-01
725,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,730,D,0,1,T9WW11,"Based on employee file review and staff interview, the facility failed to ensure performance reviews were completed at least every twelve (12) months for three (3) of three (3) randomly chosen Certified Nurse Aides (CNAs) reviewed during the Long-Term Care Survey Process. Staff identifiers: #71, #7, and #74. Facility census: 117. Findings included: a) Facility task For the Sufficient and Competent Staffing facility task, review of the employee files of three (3) randomly-chosen CNAs (CNAs #71, #7, and #74) who had been employed by the facility for at least one year, found none of them had a completed performance review during the previous twelve (12) months. During an interview on 08/30/18 at 10:00 AM, the Administrator stated the facility did not complete yearly performance reviews for CNAs.",2020-09-01
726,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,761,D,0,1,T9WW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to dispose of two (2) bottles of floor stock medications located in the cabinet of the 100 and 200 hallway medication room that were expired. Facility census: 117. Findings included: a) On 08/28/18 at 9:17 AM, inspection of the 100 and 200 hallway medication room accompanied by Licensed Practical Nurse (LPN) #90 found the following in the cabinets containing floor stock: -- A bottle of [MEDICATION NAME], an [MEDICATION NAME], had an expiration date of 07/2018. -- A bottle of zinc sulfate, a nutritional supplement, had an expiration date of 05/2018. The expiration dates were verified by LPN #90, and she agreed the medications were expired. She stated she would discard the bottles of expired medications. On 08/28/18 at 9:20 AM, Nurse-Unit Manager LPN #20 was informed about the two (2) bottles of expired floor stock medication. She had no further information regarding the matter.",2020-09-01
727,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,772,D,0,1,T9WW12,Deficiency Text Not Available,2020-09-01
728,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,773,D,0,1,T9WW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain and/or notify the physician of laboratory (lab) results for three (3) of twenty-six (26) residents reviewed during the Long Term Care Survey Process. The facility failed notify the physician of the results of a STAT (immediate) lab order for a Basic Metabolic Panel (BMP) and Complete Blood Count (CBC). For Resident #34, the facility failed to obtain a physician ordered [MEDICATION NAME] level, and for Resident #89, the facility failed to obtain a physician ordered BMP. Resident Identifiers: #12, #34, and #89. Facility Census: 117. Findings included: a) Resident #12 A review of Resident #12's medical record at 1:33 p.m. on 08/27/18, found on 07/24/18, Resident #12 was found unresponsive in the morning hours. His vital signs were obtained and found to be normal. The change in condition was reported to the resident's attending physician at 12:27 a.m. on 07/24/18. The only order noted at that time was to continue to monitor resident. Further review of the resident's record found an additional progress note dated 7:39 p.m. on 07/24/18, STAT BMP (Basic Metabolic Panel) and CBC (Complete Blood Count) obtained on 07/24/18 at 6:00 p.m. awaiting results from (name of local hospital). A review of the resident's record found a physician's orders [REDACTED]. The order itself indicated the labs were obtained on 07/24/18 at 6:00 p.m. Further review of the record found no results for this lab obtained on 07/24/18. An interview with the Director of Nursing (DON) at 9:17 a.m. on 08/29/18, confirmed the results of the lab obtained on 07/24/18 were not contained in the resident's medical record. She contacted the medical records department and found they did not have the results either. She then spoke with Registered Nurse (RN) #12 who was the unit manager for Resident #12's unit. RN #12 indicated she did not have the lab either. While the DON was attempting to track down the original lab, License Practical Nurse (LPN) #57 called the local hospital who completed the lab work and obtained a copy of the lab results which she provided to the surveyor. A review of this lab result found Resident #12's WBC was high at 15.81. The DON then reviewed the progress notes and confirmed the physician was never notified of these results. A follow up interview with the DON and Nursing Home Administrator (NHA) at 11:24 a.m. on 08/30/18 revealed they had notified the attending physician of the resident's lab work for 07/24/18 yesterday on 08/29/18 after it was brought to their attention by the surveyor. b) Resident #34 Record review found a physician order [REDACTED]. - Discontinue [MEDICATION NAME] Sprinkles 50 milligrams (mg) by mouth BID (two times a day). - Start [MEDICATION NAME] Sprinkles 250 mg by mouth BID. The [MEDICATION NAME] was ordered for a [DIAGNOSES REDACTED]. - Obtain a [MEDICATION NAME] level in 2 (two) weeks. On 08/29/18 at 9:56 AM, Assistant Director of Nursing (ADON) #57 confirmed the [MEDICATION NAME] level had not been obtained as directed by the physician on 04/23/18. c) Resident #89 Review of Resident #89's medical records found a physician's orders [REDACTED]. Discontinue BMP every 91 (ninety-one) days. Laboratory results were reviewed and found the BMP scheduled in two (2) weeks was obtained on 07/31/18 (approximately 4 weeks). Review of nurse's notes found no evidence of laboratory tests done in the month of (MONTH) (YEAR). The facility provided a communication sheet for 07/18/18 and 07/19/18. This form noted on 07/18/18, Resident #89 refused to have blood drawn for the BMP, Magnesium level and [MEDICAL CONDITION] stimulating hormone (TSH) level. On 07/19/18, Resident #89 had blood drawn for TSH and Magnesium level. Interview with Director of Nursing (DON) on 08/30/18 at 10:15 am, confirmed the BMP was not obtained on 07/19/18 with the TSH and Magnesium level. She confirmed there was no documentation regarding labs in the nurses' notes during (MONTH) (YEAR).",2020-09-01
729,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,842,D,0,1,T9WW11,"Based on medical record review, observation, and staff interview, the facility failed to ensure a complete and accurate medical record for one (1) of twenty-six (26) residents reviewed during the Long-Term Care Survey Process. Resident #114's skin check dated 08/25/18 was incomplete and inaccurate. Resident identifier: #114. Facility census: 117. Findings included: a) Resident #114 Review of Resident #114's medical record found a weekly skin check dated 08/18/18 which reported previously noted skin injury/wounds of deep tissue injury (DTI) to the coccyx, bilateral heels, and left second toe. A weekly skin check dated 08/25/18 reported no identified skin injury/wounds. Observation of Resident #114 with Nurse-Unit Manager Licensed Practical Nurse (LPN) #20 on 08/28/18 at 1:23 PM revealed DTI to Resident #114's bilateral heels and left second toe. The coccyx was not observed due to resident comfort, but LPN #20 confirmed the resident currently had a DTI on her coccyx. LPN #20 stated the skin check dated 08/25/18 was incorrect and should have documented pre-existing skin injuries/wounds on the coccyx, bilateral heels, and left second toe. She stated she would correct the skin check.",2020-09-01
730,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,867,E,0,1,T9WW12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, resident interview, policy review, and infection control monthly line listing the facility failed to maintain an effective Quality Assurance Program to develop and implement appropriate plans of action to correct quality deficiencies of which it had or should of had knowledge. The facility failed to ensure an accurate assessment, failed to develop/implement a person =centered care plan, failed to revise care plans, failed to maintain an environment free of accident hazards, failed to complete post [MEDICAL TREATMENT] forms, and failed to maintain a complete infection control surveillance/tracking Resident identifiers: #304, #64, #72, #305, and #303. Facility census: 116. Findings included: a) Accuracy of Assessments 1. Resident #11 A review of the Medication Administration Record [REDACTED]. The resident received this medication throughout the month of October. A review of the resident's care plan revealed a focus area dated 04/17/18 which stated (name of resident) has a [DIAGNOSES REDACTED]. A review of the minimum data set (MDS) with an assessment reference date (ARD) of 11/01/18, Section N (Injections) Record the number of days that injections of any type were received during the last seven days or since admission/entry or reentry if less than days. This was recorded as 0. Section N0350 (Insulin) stated Insulin Injection- Record the number of days that insulin injections were received during the last 7 days or since admission/readmission. This was question was left blank. The MAR indicated [REDACTED]. An interview with the MDS coordinator on 11/14/18 at 12:52 PM revealed the MDS was not accurate for Section N0300 (Injections) and N0350 (Insulin). A review of the skin integrity report for Resident #11 revealed the resident had a stage II pressure ulcer to the coccyx. The skin report reflected the Stage II on the coccyx on 10/19/18, 10/24/18, 10/31/18, and 11/07/18. On 10/06/18, 10/10/18, and 10/17/18 the skin report reflected the area on the coccyx as an unstageable pressure ulcer. According to the resident assessment inventory (RAI) manual, Once the pressure ulcer is debrided of slough and/or eschar such that the anatomic depth of soft tissue damage involved can be determined, then code the ulcer for the reclassified stage. The pressure ulcer does not have to be completely debrided or free of all slough and/or eschar tissue for reclassification of stage to occur. A review of the MDS with an ARD of 11/01/18 section M reflected the resident did not have a Stage II pressure ulcer. An interview with MDS coordinator on 11/14/18 at 5:03 PM revealed the MDS was incorrect for the area of Stage II pressure ulcers. b) Comprehensive Care Plans 1. Resident #64 Review of Resident #67's Medication Administration Record [REDACTED]. Review of the care plan found no evidence Resident #67 having an implanted venous port. On 11/04/18 the director of nursing (DON) explained Resident #67 has had the port for several years but could not find the date of placement. The DON also agreed Resident #64's care plan does not include evidence of the port existence or interventions to care for the port. c) Care plan timings 1. Resident #72 Review of the medical record on 11/13/18 found this resident and/or family elected to discontinue hospice services in September, (YEAR) A significant change minimum data set (MDS) with assessment reference date (ARD) of 09/18/18, assessed that he no longer received hospice services. A physician's orders [REDACTED]. Another physician order [REDACTED]. The latter was a verbal order from the doctor to a nurse. Review of the care plan on 11/13/18 found it still contained interventions related to hospice services. Interventions on the current care plan included the following: - Arrange visits with pastoral care, social worker, psychological services as indicated and desired. This intervention was created and initiated on 04/20/18. - Collaborate with hospice program to coordinate plan of care. This intervention was created and initiated on 04/20/18, and a revision date of 09/13/18. - Provide palliative care, dying process, bereavement, as needed per protocol. This intervention was created and initiated on 04/20/18. An interview was conducted with the director of nursing (DON) on 11/14/18 at 11:30 AM, while in the presence of the administrator. She reviewed the care plan on her computer. She agreed that the care plan was not revised to address the discontinuation of hospice services. 2. Resident #11 A review of the care plan for Resident #11 reflected a focus area which stated the resident required assistance in transfers. The interventions listed included, see transfer/lift assessment. The lift assessment dated [DATE] reflected the resident required a total lift for transfers. The resident was assessed as being non-weight bearing and not being able to transfer independently with supervision or without this use of a device. A focus area on the care plan for the resident's risk for falls included an intervention to assist resident getting out in out of bed with assist of one person and gait belt for transfer. An interview with the director of nursing (DoN) and Nurse Aide #8 on 11/14/18 at 11:14 AM revealed Resident #11 required the use of a lift for transfers. The DoN said she realized the conflicting information present in the care plan under the ADL and fall section and would make a revision to reflect the resident's requirement of the use of a lift for transfers. d) Accident hazards 1. Resident #304 Review on 11/12/18 of the facility's Assessment History Report for lifts and transfer revealed that this resident on 10/19/18 was assessed as as needing a a total lift with a full body sling size large. The score assigned on this report was 47.0. The electronic medical record care plan was reviewed on 11/13/18, as was a hard copy of the current care plan provided by the director of nursing (DON). The current care plan contained a focus that this resident was at risk for falls related to impaired mobility and fall history. A current intervention, which was initiated and created on 11/02/18, directed that a mechanical lift (be) used for transfers. Review of the electronic medical record Kardex directed to refer to the lift assessment for transfers. On 11/14/18 at 9:00 AM an interview was conducted with Resident #304. Upon inquiry as to how he transfers from the bed to the wheelchair, he said he just stands up and sits down in the wheelchair. When asked if he uses a mechanical lift of any kind or body sling during the transfers from the bed to the chair, he replied in the negative. When asked the number of nursing assistants who help him transfer from the bed to the chair and vice versa, he said one (1) aide helps him. He said they do not want him to transfer by himself. An interview was conducted with nursing assistant #55 on 11/14/18 at 9:10 AM. She said she is a float working the back hall today and is assigned to his room, but she has never worked with this resident before. When asked how he transfers from the bed to the chair, she said she believes they use a gait belt to transfer him. She said there is a lift assessment book at the nurse's station that they can refer to to find out how each resident transfers. She said that information is also written on the door by the resident's name. At this time, we referred to the tag on the door by this resident's name. The tag at the door directed that he was a total lift for transfers who used a full body sling size large. At 9:10 AM on 11/14/18, NA #55 entered the resident's room. When asked in front of NA #55 how he transfers from the bed to the wheelchair, he said he just stands up and turns around and sits down. He said he never uses a mechanical lift, but his room mate does. At this time his room-mate (Resident #105) spoke up and said that two (2) aides assist him (R#105) with transfers out of bed via a mechanical lift. He said that they do not use a mechanical lift for transfers out of bed for Resident #304. On 11/14/18 at 9:15 AM an interview was conducted with unit manager LPN #71. She said they formerly had a lift assessment book at the desk, but they discontinued its use when they changed to electronic medical records. When LPN #71 was informed that Resident #304's Kardex direct staff to refer to the lift assessment, she said that the information on the lift assessment is also located on each resident's front door. She said Employee #19 is the admissions co-coordinator, and is the person responsible for putting the stickers on the residents' doors based on the lift assessments upon admission. LPN #71 was informed that the information on the resident's door directs that he is a total lift with the need for a size large sling, although he says he does not use a mechanical lift for transfers At 9:20 AM on 11/14/18 unit manager LPN #71 printed a copy of the most recent Lift Transfer Reposition form which was dated 10/24/18 by registered nurse #11. This lift Transfer Reposition assessment stated the following: - [NAME] Assessment -1. Is the patient able to transfer independently or with supervision without using a device? No. -2. Is the patient able to weight-bear equal to of greater than 50 percent on one or both legs? No. - 5 e was checkmarked that total lift was required. -6 Number of staff needed for repositioning in bed: Two (2) -B. Specifications/sizes b. Total lift, size sling size large, based on weight of 163.8 pounds on 10/20/18. At this time, LPN #71 said she updated his assessment, and will provide a copy of it after she enters it into the electronic health record. An interview was conducted with nursing assistant #32 on 11/14/18 at 9:35 AM. She said she has worked with Resident #304 before, although she is not assigned to him today. She said she always uses a gait belt when helping to transfer Resident #304 from the bed to the chair and vice versa. She said he stands and pivots. She said they do not use a mechanical lift to transfer him. She said they use a mechanical lift for his room-mate for transfers out of bed. Review on 11/14/18 of the minimum data set (MDS) with assessment reference date (ARD) 09/29/18 found a brief interview for mental status (BIMS) score assessment of fifteen (15). A score of fifteen (15) indicates intact cognitive functioning. Review of his room-mate's (Resident #105) MDS, with ARD of 09/29/18, found a BIMS score assessment of fifteen (15). Another BIMS assessment dated [DATE] also assessed his score of fifteen (15). On 11/14/18 at 9:45 AM LPN unit manger #71 provided a copy of the updated Left Transfer Reposition with effective date 11/14/18 at 9:24 AM. Per this assessment, it was determined that a gait/transfer belt is required for transfers. An interview was conducted with the administrator on 11/14/18 at 11:30 AM. He said using the gait belt rather than a mechanical lift caused no harm to the resident. He surmised that the resident got stronger due to therapy services and subsequently improved to the use of a gait belt for transfers. It was discussed that the nursing assistant and the resident and the resident's room-mate reported that his transfers were being done without the use of a mechanical lift. However, the tag at the resident's door which gave directive for nursing assistants to follow, directed to use a lift and a large sized body sling for transfers. The Kardex which the nursing assistants use directed to refer to the lift assessment for transfers. The lift assessment, dated 10/19/18, directed to use a full body sling size large and a total lift for transfer. An intervention care planned on 11/02/18 directed the use of a mechanical lift for transfers. This practice indicated that the nursing assistants were using their own judgment for completing transfers rather than the written directive on the Kardex and/or care plan, and/or lift assessment, and/or directive on the door frame of the resident's room. The administrator said he would look through the medical record and therapy notes to see if perhaps the order had changed to transfers with a gait belt. No further information was provided prior to exit. e) [MEDICAL TREATMENT] 1. Resident #303 Review of records, on 11/13/18 at 2:15 PM, revealed Resident #303 receives [MEDICAL TREATMENT] on Monday and Fridays at a [MEDICAL TREATMENT] center. Review of the [MEDICAL TREATMENT] Communication book revealed the post [MEDICAL TREATMENT] section of the [MEDICAL TREATMENT] communication record forms are not completed as required by nursing, when the resident returns to the facility from the [MEDICAL TREATMENT] center after having [MEDICAL TREATMENT]. The post section of the [MEDICAL TREATMENT] communication forms, which are to be completed in its entirety by the facility nurse when the resident returns to the facility, were not consistently filled in with the information the form required or that was individualized to reflect Resident #303 status. The [MEDICAL TREATMENT] communication form requested the following information in the Post-[MEDICAL TREATMENT] section: an assessment including the access site, whether there is any swelling, drainage, or pain. For a resident with an AV (Arteriovenous) Shunt only, Bruits or Thrills should be assessed, and should be marked plus (+) or minus (-) to indicate whether any are present. 'Yes' or 'No' is to be marked to indicate if there are any new orders from the [MEDICAL TREATMENT] Center. Lastly there are blank lines available for the nurse to make narrative notes concerning the resident's condition or any other pertinent information such as vital signs (VS), which includes blood pressure, pulse, temperature, and respirations. On 10/17/18 and 10/26/18 only vital signs (VS) was recorded in the narrative notes section, but no other information was noted, nothing to indicate if there were or were not any new orders or any assessments made of the site to ensure the dressing was in place and was dry and intact. On 10/24/18 and 10/29/18 only information provided concerned new orders, and it was marked 'No' indicating there were no new orders from [MEDICAL TREATMENT] Center for those visits. On 10/29/18 the [MEDICAL TREATMENT] nurse dated the [MEDICAL TREATMENT] section 10/29/18, however the facility nurse dated the post section 10/20/18. On 10/31/18 the only information completed was the AV shunt assessment, however the resident does not have a shunt. Resident#303 has a perma-cath (catheter) and that assessment is not applicable to this particular resident,. For a perma- cath the nurses need to ensure the dressing is dry with out drainage nd intact. On 11/02/18 and 11/05/18 the facility did not complete any information on the post-[MEDICAL TREATMENT] section, the section was left completely blank with no marked areas or any narrative notes. Review of the F698 [MEDICAL TREATMENT] & Proper BP Documentation Audit ([MEDICAL TREATMENT] and Proper Blood Pressure Documentation Audit, on 11/13/18 at 3:32 PM, revealed the audit reflected no issues found for Resident #303. The category columns listed for review were 'Resident', 'Date', 'Communication Book Complete?', 'BP (blood pressure) documented correct?', and 'Corrective Action Needed'. This surveyor's review of the [MEDICAL TREATMENT] communication record forms dated 10/17/18, 10/24/18, 10/26/18, 10/29/18, 10/31/18, 11/02/18, and 11/05/18, revealed the forms were not complete and corrective actions were needed. The audit sheet revealed on these dates the communication book form was complete, and no corrective action were needed. Review of the facility's plan of correction, on 11/13/18 at 3:45 PM, revealed the DON/designee will re-educate all involved licensed nursing staff ensuring all [MEDICAL TREATMENT] Communication Records are completed prior to and in their entirety after every [MEDICAL TREATMENT] trip according to policy. Another intervention in the plan of correction included, .will reeducate all licensed nurses concerning . the completion of the [MEDICAL TREATMENT] Communication Record prior to and upon return on or before 10/11/18 with a post-test to validate understanding. Nursing staff was re-educated, and a post test was given. A Review of the POS [REDACTED]. The correct answer to question number 1 was 'false', When a resident is receiving [MEDICAL TREATMENT], it is not important which extremity blood pressures are taken in. Indicating it is important which extremity blood pressures are taken in. The correct answer to question number 2 was 'true', When documenting blood pressures on a [MEDICAL TREATMENT] resident, the nurse should be cautious to document the correct extremity it is taken in. The correct answer to question number 3 was 'true', The [MEDICAL TREATMENT] communication form is to be completed entirely with each [MEDICAL TREATMENT] treatment. The correct answer to question number 4 was 'false', It is ok to just write a note when a resident returns from [MEDICAL TREATMENT] if the nurse does not want to complete the [MEDICAL TREATMENT] communication sheet. Indicating the form must be filled out. On 11/13/18 at 4:00 PM, an interview with the Unit Manager, Licensed Practical Nurse (LPN#71) and Staff#13 (Medical Records) who was responsible for completing the audit, confirmed the post-[MEDICAL TREATMENT] section of the [MEDICAL TREATMENT] communication record forms were not properly filled out and the audit was not correct. Staff#13 (Medical Records) stated she thought it was complete because the resident did not have a shunt but a perma-cath and nurses chart by exception. Staff#13 said some of the information was also charted on the Treatment Administration record (TAR). When asked how the [MEDICAL TREATMENT] center would know what was charted on the TAR to ensure continuity of care or why the nurses did not at least check 'yes' or 'no' concerning whether there were any new orders from the [MEDICAL TREATMENT] center. Staff#13 did not answer, but agreed the forms were not filled out as the nurses should have, and the audit was wrong. LPN#71, who helped to create the plan of correction, said the intend was to make the post-[MEDICAL TREATMENT] section of the Communication Record complete, there should not be any blanks left on the form. On 11/15/18 at 11:48 AM, review of the facility's policy titled, [MEDICAL TREATMENT] Communication and Documentation revealed the following Practice Standards: 1. Prior to a patient leaving the center for outpatient [MEDICAL TREATMENT] treatment, a licensed nurse will complete the top portion of the [MEDICAL TREATMENT] Communication Record or the state required form and send with the patient to his/her out patient [MEDICAL TREATMENT] center visit. 2. Following completion of the out-patient [MEDICAL TREATMENT] treatment, the [MEDICAL TREATMENT] nurse should complete the form and return it or other communication to the Center with the patient. 3. Upon return of the patient to the center, a licensed nurse will: 3.1 Review the [MEDICAL TREATMENT] center communication; 3.2 Evaluate/observe the patient; and 3.3 Document the evaluation/observation on the [MEDICAL TREATMENT] Communication Record or state required form. 4. Notify the [MEDICAL TREATMENT] center if the form is not returned with the patient and ask that it be faxed to the center. 4.1 Document notification of [MEDICAL TREATMENT] center regarding return for form or other communication. 5. Maintain the [MEDICAL TREATMENT] Communication Record or state required form in the patient's medical record. f) Infection control The month of (MONTH) (YEAR) infection control monthly line listing review includes twenty-two (22) separate line listings on or after the plan of correction date of 10/11/18. Of these 22 line listings sixteen (16) were incomplete. The infection control monthly line listing includes the following columns: Name Room number admitted Date onset HAI/C ( Hospital or community acquired) Type of Symptoms/Diagnosis Culture/Chest x-ray with Date taken, Site, and Results Treatments with ABT (antibiotic type) and Start date Precaution type Infection resolved (date) On 11/14/18 at 4:00 PM the director of nursing (DON) was asked to complete the missing information on the infection control monthly line listing for (MONTH) (YEAR). This request was made to determine if the information was readily available on other documentation. Approximately forty-five minutes later information was obtained to complete the line listing for three (3) residents. These residents are not included in this listing. The interview ended on 11/14/18 at 5:00 PM. The line listings include; 1. Resident #410 This resident was admitted with possible pneumonia with the date of onset being 10/24/18. The listing did not include information concerning if the resident was on an antibiotic, if a culture or x-ray was obtained, and if the infection was resolved. 2. Resident #411 This resident receiving Bactrim for a hospital acquired infection (HAI), with an start date of 10/19/18. The line listing did not include, what the medication was given for, if a culture or chest x-ray was obtained, the type of precaution, or if the infection was resolved. 3. Resident #305 This resident received [MEDICATION NAME] beginning 10/24/18 [MEDICATION NAME] 10/31/18 for a urinary tract infection [MEDICAL CONDITION]. The documentation does not include, if a culture was obtained or if the infection was resolved. 4. Resident #412 The type of infection, if a culture or x-ray was obtained and the precaution type. 5. Resident #413 This resident onset of [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) or information concerning the precaution type or resolved date. 6. Resident #59 This resident had a HAI pneumonia with an onset of 10/24/18. The listing does not include if a culture or x-ray was obtained, a precaution type or the date resolved. 7. Resident # 415 This resident had HAI [MEDICAL CONDITIONS] with an onset of 10/18/18. There is no indication of the precaution type or the resolved date. 8. Resident #309 Did not have a date resolved for [MEDICAL CONDITION] with an onset of 10/17/18. 9. Resident #308 Did not identify if a culture was completed for a UTI with an onset date of 10/19/18. Also missing was the precaution type and the resolved date. 10. Resident #416 This resident had [MEDICAL CONDITION] on an onset of 10/19/18. There is no evidence if a culture was completed, a precaution type or if the infection was resolved. 11. Resident #417 Includes the date of onset of 10/22/18, with no identification of organism or location. Ciproflaxacin was prescribed. There is no evidence if a culture was completed, a precaution type, or if the infection was resolved. 12. #306 This resident being treated for [REDACTED]. There is no evidence if a culture was completed, the precaution type or the resolved date. 13. #418 An onset of [MEDICAL CONDITION] on 10/12/18 and pneumonia onset of 10/27/18 with no evidence of the resolved date. 14. #419 An onset of [MEDICAL CONDITION] on 10/20/18 with no evidence if a culture was obtained or when the infection was resolved. 15. Resident #61 An onset of pneumonia on 10/26/18 with no evidence if a culture was obtained, a precaution type or resolved date. 16. Resident #75 An onset [MEDICAL CONDITION] on 10/26/18 with no evidence of the type of precautions or a resolved date. On 11/15/18 at 11:30 AM the administrator provided an electronic clinical outcomes report for the month of (MONTH) (YEAR). The report includes the numerical number of healthcare acquired; infections, urinary tract infections, pneumonia, [MEDICAL CONDITION], and multi-drug resistant organism (MDRO). The report did not include other tracking information. The facility infection control outcome surveillance and reporting form with a review date of 11/15/18 section 4 includes guidance to facility staff as When an infection is identified, designated staff will document infection on the Infection Control Monthly Line Listing. Section 4.5 also directs staff to Provide information for Monthly Infection Control Report. On 11/15/18 at 12:00 PM the administrator expressed concerns about the facility receiving a tag related to infection control when the revisit did not find specific resident issues concerning infection control.",2020-09-01
731,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,880,L,0,1,T9WW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, resident interview, review of facility policies, review of the facility's infection control monthly line listings, review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed prevent the spread of infection to the extent possible by implementing contact precautions for residents whose urinary tract infections [MEDICAL CONDITION] included multi-drug resistant organisms. Record review and review of the line listings found five (5) residents identified as having Extended Spectrum Beta lactamase in two (2) months - (MONTH) and (MONTH) (YEAR). (Beta lactamases are enzymes produced by many species of bacteria which destroy one or more antibiotics. It is one of the ways in which bacteria develop resistance.) Observations and staff interviews confirmed contact precautions, in addition to standard precautions, were not employed. Due to the potential for the exposure to other residents, staff, and visitors, an immediate jeopardy to the health and well-being of others was determined. The Administrator and the Director of Nursing were notified of the determination of the immediate jeopardy on 08/29/18 at 2:48 PM and a brief statement of the deficient practice provided. The facility provided an acceptable plan of correction (P[NAME]) at 5:18 PM at which time the immediate jeopardy was removed as implementation of the P[NAME] had occurred. Resident identifiers: #31, #12, #80, #104, #99. After removal of the immediate jeopardy, deficient practices remained at a scope and severity of [NAME] for failure to cohort residents in keeping with infection control. Resident #33, a debilitated resident with a suprapubic catheter was residing in the same room as Resident #31, who had a multi-drug resistant urinary tract infection. Additionally, items such as straws, cups, and plastic utensils were stored under the sink in the medication room where contamination was a potential. This had the potential to affect more than a limited number of residents. Findings include: a) Resident #31 Observation and interview with the resident at 9:05 AM on 08/27/18, found the resident said he was receiving an IV (intravenous) antibiotic for a urinary tract infection. Review of the medical record on 08/29/18 found the physician ordered a urinalysis with culture and sensitivity (UA C&S) on 08/21/18. The lab called the facility with the results of the culture and sensitivity, which identified the urine was positive for ESBL (Extended-Spectrum Beta-Lactamase), Escherichia coli (E-coli), and Proteus Vulgaris, on 08/24/18. At 12:35 PM on 08/29/18, the resident's Nursing Assistant (NA), NA #21, said she was aware the resident had a urinary tract infection. She said the resident was incontinent of urine and wore gloves when providing incontinence care and always washed her hands. At 12: 45 PM on 08/29/18, the resident's Licensed Practical Nurse (LPN). LPN #42 said she was aware the resident had ESBL and E-coli in his urine. She said, We follow standard precautions, which is wearing gloves and hand washing when providing incontinence care. At 12:50 p.m. on 08/29/18, the Director of Nursing (DON) said, We follow the CDC (Centers for Disease Control and Prevention) guidelines and the resident does not require isolation, only standard precautions. The ESBL is contained in the resident's brief. b) Resident #80 The laboratory report for a urine sample collected 08/23/18 with the final report dated 08/25/18, included, This is an ESBL positive organism, it is considered a multi-drug resistant organism. It also confers resistance to the beta-lactam antibiotics such as [MEDICATION NAME], cephalosporins, and aztreonam. According to the lab report, the final results were called to the facility. On 08/26/18, an order was written for, Ertapenem for ESBL in urine. (Ertapenem is a broad spectrum carbapenem antibiotic.) Random observations on 08/27/18, 08/28/18/, 08/29/18, and 08/30/18 did not find signage posted on the resident's door to alert those entering the room to check with the nurse and/or identify additional precautions were needed. c) Resident #104 Review of the Infection Control Monthly Line Listing on 08/29/18 found Resident #104's name listed as having a urinary tract infection [MEDICAL CONDITION]. According to the line listing, the resident was [MEDICATION NAME] 08/20/18. Review of the resident's medical record on 08/29/18 did not find the results of the culture and sensitivity (C&S). At approximately 10:30 AM, the Director of Nursing (DON) was asked for the report for the C&S. The results of the C&S were provided at 12:30 PM. According to the copy of the report provided, the report was faxed to the facility on [DATE] at 12:06 PM, however, the report was dated as final on 08/25/18. The report identified E. Coli ESBL. Random observations on 08/27/18, 08/28/18/, 08/29/18, and 08/30/18 did not find signage posted on the resident's door to alert those entering the room to check with the nurse and/or identify additional precautions were needed. d) Resident #99 Review of the facility's infection control line listing for (MONTH) (YEAR) found this resident also had ESBL in her urine. The resident was ordered Bactrim DS on 07/05/18. The line listing did not indicate the resident was place on contact precautions. The C&S report dated 07/05/18 confirmed the resident had ESBL in her urine. e) Resident #12 A review of Resident #12's medical record at 1:33 p.m. on 08/27/18 found an order for [REDACTED].#12 returned from the hospital. The stop date for this antibiotic was 08/28/18. The reason listed for this medication was ESBL E. coli UTI/Sepsis. Further review of Resident #12's medical record found an Antimicrobial Susceptibility and Organism Report for a local hospital dated 08/17/18 which was reported on 08/22/18. This report indicated Resident #12's blood culture was ESBL positive E. coli. The report indicated the laboratory notified Licensed Practical Nurse (LPN) #29 at the facility on 08/22/18 at 10:45 a.m. Observations of Resident #12 at 10:00 a.m. on 08/27/18 found the resident resting in his room. His IV pole and pump were at his bedside and his completed IV bag was still hanging on the pole, but was not running at the time of the observations. There was no signage on the door, nor was there any personal protective equipment (PPE) by the door. There was nothing observed to indicate the resident was on contact precautions on 08/27/18 or 08/28/18, while being actively treated for [REDACTED]. An interview with the Director of Nursing (DON) on 08/29/18 in the afternoon confirmed that Resident #12 was not placed in contact isolation because their infection control policy did not warrant contact isolation for residents with ESBL. Further review of Resident #12's medical record found that on 17 occasions during the seven (7) days Resident #12 was being actively treated for [REDACTED]. Observations of Resident #12's room found that Resident #12 shared a bathroom with Resident #75. A review of Resident #75's medical record on 08/29/18 at 3:00 p.m. found he had a wound vac to an open wound on his coccyx. A review of his activities of daily living (ADL) documentation found that he was continent of both bladder and bowel. A review of the ADL documentation for the time frame of 08/22/18 through 08/28/18 (the time Resident #12 was actively treated for [REDACTED].#75 was continent of urine in the toilet on 18 times and was continent of bowel on 11 occasions. On these occasions, Resident #75, who had an open area to his coccyx, was using a toilet that was shared with Resident #12 who was positive for ESBL in both his blood and his urine. f) Review of the minimum data sets (MDS) for Residents #31, #12, #80, #104, and #99 found only one resident, Resident #104, was admitted since (MONTH) (YEAR). The MDS records did not indicate the other residents had a discharge and/or reentry record identifying a hospital stay prior to having a urine culture identifying ESBL. However, record review identified Resident #12 had been hospitalized [DATE] to 08/21/18, where the ESBL was identified. g) CDC classifies ESBL as a serious threat The list of Serious Threats at https://www.cdc.gov/drugresistance/biggest_threats.html includes: Multidrug-resistant Acinetobacter Drug-resistant Campylobacter Fluconazole-resistant Candida Extended-spectrum Beta-lactamase producing [MEDICATION NAME] [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE) CDC guidelines, Appendix A, includes recommendations for individuals with active ESBL infections be placed on contact precautions. h) The facility provided a copy of its infection control policy/procedure for multi-drug resistant organisms (MDROs). The procedure included to, 3. Clinically document the level of risk for transmission . Instruct staff, patient, and visitors regarding the level of Precautions needed and use of personal protective equipment. No evidence was found to support these elements were implemented. i) According to these findings, Residents #31, #104, #12, and #80 were all being treated with antibiotics for ESBL producing organisms in their urine. On 08/30/18 at 11:22 AM, an interview with a representative of the local health department found the facility had not reported an outbreak of ESBL. j) Due to the potential for the exposure to other residents, staff, and visitors, an immediate jeopardy to the health and well-being of others was determined. The Administrator and the Director of Nursing were notified of the determination of the immediate jeopardy on 08/29/18 at 2:48 PM and a brief statement of the deficient practice provided. The facility provided an acceptable plan of correction (P[NAME]) at 5:18 PM at which time the immediate jeopardy was removed as implementation of the P[NAME] had occurred. k) Facility's Plan of Correction (P[NAME]) Resident #31 and resident #80 was placed in contact isolation by the Director of Nurses/designee immediately upon discovery. Resident #99, resident #104, and resident #12 are no longer receiving treatment, are not symptomatic therefore require standard precautions. All residents of the facility have the potential to be affected. Director of Nurses/designee checked all residents for active cases of ESBL on 8/29/18 to ensure contact precautions were implemented for all residents with ESBL who are receiving active treatment. The Performance Development Specialist (PDS)/designee will provide reeducation regarding placing residents in contact isolation when a resident is actively being treated for [REDACTED]. Licensed nurses not available during this timeframe will be provided reeducation including posttest by the PDS/designee upon return to work. New licensed nurses will be provided education and complete posttest during orientation. The PDS/designee will audit residents upon admission, readmission, and residents with active symptoms of ESBL and randomly thereafter to ensure residents are placed in contact isolation. Trends identified will be reviewed by the PDS/designee monthly at the Quality Improvement Committee (QIC) for any additional follow up and/or inservicing until the issue is resolved and randomly thereafter as determined by the QIC committee. l) After removal of the immediate jeopardy, deficient practices remained at a scope and severity of [NAME] for failure to cohort residents in keeping with infection control. Resident #33, a debilitated resident with a suprapubic catheter was residing in the same room as Resident #31, who had a multi-drug resistant urinary tract infection. Additionally, items such as straws, cups, and plastic utensils were stored under the sink in the medication room where contamination was a potential. This had the potential to affect more than a limited number of residents. m) Resident #33 Resident record reviews and observations found Resident #33, who had a suprapubic catheter and was on comfort measures, was housed with a resident who was receiving IV antibiotics for an active ESBL producing E. Coli infection (an MDRO). The facility's policy/procedure regarding MDROs includes, 7. When cohorting patients with the same MDRO is not possible, place MDRO patients in rooms with patients who are at low risk for acquisition of MDROs and associated adverse outcomes from infection. The facility's policy indicated Resident #33 should not have been cohorted with Resident #31. n) Facility task On 08/28/18 at 9:17 AM, inspection of the 100 and 200 hallway medication room was conducted. The surveyor was accompanied by Licensed Practical Nurse (LPN) #90. The cabinet immediately below the sink was observed to contain straws, spoons, and plastic cups. The left side of the cabinet was inaccessible due to a screw that had been placed in the cabinet door. The right side of the cabinet had a hole where a screw had once been located. However, the screw was no longer in place and the cabinet door could be opened freely. LPN #90 stated items should not be stored under the sink due to potential contamination from the sink pipes. She stated she would have the items removed and discarded. On 08/28/18 at 9:20 AM, Nurse-Unit Manager LPN was notified about the items stored under the sink in the 100 and 200 hallway medication room. She stated she would have the items replaced and ensure the screw was replaced in the cabinet door to ensure the door could no longer be opened.",2020-09-01
732,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,925,D,0,1,T9WW11,"Based on observation, resident interview, resident representative interview, and staff interview, the facility failed to ensure an effective pest control program. Resident #93 had flies in his room that would light on his feet and face. This was a random opportunity for discovery. Resident identifier: #31. Facility census: 117. Findings included: a) Resident #31 Observation of the resident at 10:30 AM on 08/27/18, found several flies in the resident's room. Flies were on the residents feet and head area. When asked about the flies, the resident said he would just eat them if they bothered him. During a telephone call with the resident's court appointed guardian, the Department of Health and Human Services (DHHR), at 11:00 AM on 08/27/18, the representative with the DHHR said she had been concerned about the amount of flies in the resident's room. She said she talked to the facility and expected the situation would be taken care of. She observed the flies the prior week during a visit with the resident. Observation of the resident again on 08/28/18 at 5:00 PM, found there were less flies in the room; however, a fly was still present on the resident's shoulder. By the time the administrator returned to the resident's room at 5:08 PM on 08/28/18, the fly was gone. The administrator said he would have staff clean the room.",2020-09-01
739,CORTLAND ACRES NURSING HOME,515063,39 CORTLAND ACRES LANE,THOMAS,WV,26292,2017-01-12,225,D,0,1,97BS11,"Based on grievance reviews, abuse/neglect policy review, bed making policy review, and staff interviews the facility failed to ensure investigated allegations of neglect were reported to state agencies in a timely manner. Two (2) of eleven (11) grievances were not reported as required. Resident identifiers: #11 and #101. Facility census: 90. Findings include: a) Resident 11 A grievance form dated 01/09/17, documented by registered nurse, (RN) #112, revealed Resident #11 was discovered to be laying in the bed with a clean pad on top of a soiled pad which had a large area of wetness and bowel particles. The investigation revealed a nurse aide (NA) who was finishing a sixteen (16) hour shift, had placed to clean pad over the soiled pad, because it was the end of her shift. A review of the facility's bed making policy with a revision date of 05/16 revealed a policy statement of, Residents will have beds clean, wrinkle free and tidy with the policy interpretation and implementation, number one (1) being, Beds will be routinely changed and cleaned on a weekly basis, when soiled with body fluids or food and drink. b) Resident #101 A grievance form dated 12/10/16 documented by RN #112, revealed a family member for Resident #101 was informed by a visitor that her relative was incontinent of bowel and was not being cared for. A review of the facility's abuse reporting policy with a revision date of 05/16 number one (1) reveals, a suspected violation neglect will be promptly reported to the administrator, or the designee whom will then promptly notify the State licensing/certification agency responsible for surveying/licensing the facility. At 2:57 p.m., on 01/12/17 the facility administrator stated she did not see these issues as being reportable but in the future will be more aware of what should be reported.",2020-09-01
740,CORTLAND ACRES NURSING HOME,515063,39 CORTLAND ACRES LANE,THOMAS,WV,26292,2017-01-12,246,D,0,1,97BS11,"Based on observation, staff and resident interview, the facility failed to ensure one (1) of thirty five (35) Stage one (1) sampled residents, received services with reasonable accommodation of their individual needs. A resident with contractures of both hands, who did not always have the ability to push the call light button, was not offered an alternative way to alert the staff of the resident's need for staff assistance. This practice had the potential to affect more than an isolated number of residents. Resident identifier: #48. Facility census: 90. Findings include: a) Resident #48 While testing the call system on 01/10/17 at 9:14 a.m., during Stage one (1) of the Quality Indicator Survey (QIS), Resident #48 was asked to push the call bell button. The resident attempted with great difficulty to push the call light button and was unable to activate the call system. Resident #48 has contractures of both hands. To ensure the call system was functioning properly, this surveyor pushed the hand held button and was able to activate the call system. Resident #48 said, I can't always push the button because of my hands. The resident was asked what she did when she was unable to push the call light button and she needed staff to help her. The resident replied, There always seems to be someone around, I just holler for them. When asked if the resident had ever told any staff she had a problem pushing the call light button, the resident replied, Yes, they know I have trouble using my hands. On 01/10/17 at 9:35 a.m., during an interview Licensed Practical Nurse Supervisor (LPN) #44 acknowledged due to Resident #48's contractures the resident would more likely find it easier to use a touch pad than a push button call light. LPN #44, said a touch pad would be provided for the resident. After surveyor intervention the push button call light was replaced with a touch pad to accommodate resident's needs. Resident #48 was observed several times using the touch pad call light without difficulty. An interview with Resident #48, on 01/11/17 at 2:13 p.m., revealed the resident said it was much easier and better to use the touch pad. The Resident expressed she was very happy with the touch pad.",2020-09-01
741,CORTLAND ACRES NURSING HOME,515063,39 CORTLAND ACRES LANE,THOMAS,WV,26292,2017-01-12,253,E,0,1,97BS11,"Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services for five (5) of twenty-eight (28) rooms observed during Stage 1 of the Quality Indicator Survey (QIS). The cosmetic imperfections included a damaged wardrobe, rusted night light casements, a wall with missing plaster and missing cove base. Room identifiers: A6, A12, B1, B11, D7. Facility census: 90. Findings include: a) Cosmetic imperfections --Room A6 observed on 01/09/17 at 3:32 p.m., had a wardrobe with missing veneer and handle. --Room A12 observed on 01/10/17 at 9:33 a.m., had a bathroom night light with a rusted casement. --Room B1 observed on 01/09/17 at 1:49 p.m., had a bathroom night light with a rusted casement. --Room B11 observed on 01/09/17 at 1:44 p.m., had an outside corner wall with missing plaster. --Room D7 observed on 01/09/17 at 1:41 p.m., had a section of missing cove base. b) Interview with Maintenance Supervisor On 01/12/17 at 1:05 p.m., the Maintenance Supervisor verified the damaged wardrobe, rusted light casements, missing plaster on a corner wall and missing cove base needed to be repaired and/or replaced.",2020-09-01
742,CORTLAND ACRES NURSING HOME,515063,39 CORTLAND ACRES LANE,THOMAS,WV,26292,2017-01-12,278,D,0,1,97BS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to identify the [DIAGNOSES REDACTED].#64. Sample size: one (1) of eighteen (18) residents. Findings include: a) Resident #64. A review of the quarterly MDS dated [DATE] revealed there was no diagnosis listed for the use of [MEDICATION NAME], an antidepressant medication. Section J of the MDS has a list of [DIAGNOSES REDACTED]. Medical record physician orders [REDACTED]. This was discussed with the MDS coordinator on 01/11/17 1:32 p.m After a review of her records, she confirmed the resident had a [DIAGNOSES REDACTED].",2020-09-01
743,CORTLAND ACRES NURSING HOME,515063,39 CORTLAND ACRES LANE,THOMAS,WV,26292,2017-01-12,279,D,0,1,97BS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to develop a comprehensive care plan for Resident #11. The care plan did not address the advance directive implementation for one (1) of one (1) residents reviewed for hospice care during Stage 2. Resident identifier: #11 Facility census: 90. Findings include: a) Resident #11 A review of the medical record on 01/11/17 revealed the Physician order [REDACTED]. An interview on 01/11/17 at 1:35 p.m., with the Licensed Social Worker (LSW) and the Director of Nursing (DON) verified the current care plan for Resident #11 did not address the resident's choices regarding her advance directive and end-of-life care.",2020-09-01
744,CORTLAND ACRES NURSING HOME,515063,39 CORTLAND ACRES LANE,THOMAS,WV,26292,2017-01-12,441,D,0,1,97BS11,"Based on observation and staff interviews, the facility failed to implement practices designed to prevent infection and/or cross-contamination for two (2) of two (2) residents reviewed for administration of nebulizer treatment during medication pass of the Quality Indicator Survey (QIS). This practiced had the potential to affect all residents who received nebulizer treatments. Resident identifier: #88 and #71. Facility census: 90. Findings include: a) Resident #88 On 01/11/17 at 9:22 a.m., observation of Licensed Practical Nurse (LPN) Supervisor #130 preparing to administer Resident #88's nebulizer treatment, revealed Employee #130 laying the mouth piece for Resident #88's nebulizer directly on an unclean surface. Employee #130 when preparing to administer Resident #88's nebulizer treatment, removed the nebulizer mouth piece from the storage container and laid it directly on the resident's turned down bed spread. The area of the turned down bed spread was an area that had been touching the resident's body. The LPN then picked up the mouth piece and gave it to the resident to use. b) Resident #71 Observation of LPN Supervisor #101, on 01/11/17 at 1:30 p.m., revealedthe LPN laying Resident #71's nebulizer face mask on an unclean surface while going to get the resident a glass of drinking water. On completion of administering Resident #71's nebulizer treatment, LPN #101 laid the face mask face down cupped over the nebulizer equipment storage bag, the inside of the mask was touching the outside of the bag. Registered Nurse (RN) #3 was present during the nebulizer treatment and verified the LPN should not have laid the inside of the mask on the outside of the bag. On 01/11/17 at 1:40 p.m., interview with RN #3 confirmed LPN #101 laid the inside of resident's nebulizer face mask on an unclean surface. The RN, who was training the LPN, instructed the LPN to throw away the face mask and get a new face mask. The RN verified the mask could have been laid upside down with the back of the mask touching the surface or the LPN could have asked the resident to hold it while she got the glass of water.",2020-09-01
745,CORTLAND ACRES NURSING HOME,515063,39 CORTLAND ACRES LANE,THOMAS,WV,26292,2018-03-14,880,D,0,1,X41Y11,"Based on observation and staff interview, the facility failed to maintain an effective Infection Control Program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. Staff failed to provide/maintain a barrier for a multi dose medication bottle when placed in a resident's room for administration. This practice has the potential to affect more than an isolated number of residents residing in the facility. Resident identifiers: #26. Facility census: 82. Findings included: a) Resident #26 During a medication administration observation on 03/14/18 at 9:00 AM, Licensed Practical Nurse (LPN) #37 entered Resident #26's room to administer oral medications and eye drops. LPN #37 placed the eye drop bottle directly on the bedside table without a barrier next to the resident's breakfast tray and personal items. LPN #37 administered her oral meds and then her eye drops. LPN #37 washed her hands, retrieved the eye drop bottle from the bedside table, placed the unclean bottle on top of the medication cart, unlocked the cart and then returned the bottle into the box inside the medication cart. Immediately following this observation LPN #37 agreed she had placed the multi dose eye drop bottle directly on the bedside table without a barrier and reported she was unaware she needed to have a barrier between the eye drop bottle and the bed side table.",2020-09-01
746,CORTLAND ACRES NURSING HOME,515063,39 CORTLAND ACRES LANE,THOMAS,WV,26292,2019-10-30,550,D,0,1,4UQE11,"Based on observation and staff interview, the facility failed to provide a dignified dining experience as evidenced by standing over a resident while assisting them to eat. Resident #21. Facility census: 89. Findings included: a) Resident #21 On 10/28/19 at 11:52 AM, Nursing Aide (NA) #180 was observed standing over Resident #21 feeding lunch. At no time did NA #180 attempt to sit down when feeding this resident. In an interview with the Director of Nursing (DON) on 10/30/19 at 10:40 AM stated that she would take care of that immediately.",2020-09-01
747,CORTLAND ACRES NURSING HOME,515063,39 CORTLAND ACRES LANE,THOMAS,WV,26292,2019-10-30,625,D,0,1,4UQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to notify the resident's representative of the bed hold policy, when Resident #6 was transferred to an acute care hospital. This was true for one (1) of three (3) residents reviewed for hospitalization s. This had the potential to affect more than a limited number of residents. Resident identifier: #6 Facility census 89. Findings included: a) Resident #6 A review of the medical record on 10/30/19 for Resident #6 revealed the resident representative was not provided a notice for bed hold when Resident #6 was transferred to an acute care hospital on [DATE]. In an interview with E157, Registered Nurse Supervisor on 10/30/19 at 11:02 AM, reported she was unable to provide any evidence the resident representative for Resident #6 had received the bed hold notice for the hospitalization on [DATE].",2020-09-01
748,CORTLAND ACRES NURSING HOME,515063,39 CORTLAND ACRES LANE,THOMAS,WV,26292,2019-10-30,695,D,0,1,4UQE11,"Based on policy and procedure review, observation and staff interview, the facility failed to ensure oxygen delivery in accordance with professional standards. This practice has the potential to affect one (1) of three (3) residents reviewed for oxygen therapy. Resident identifier: #57. Facility census: 89. Findings included: a) Resident #57 Policy and procedure titled Oxygen Auxiliary Equipment with revision date of (MONTH) (YEAR) was reviewed. The policy and interpretation and implementation stated that all oxygen tubing will be changed on the 15th of each month. The policy and procedure did not state anything about evidence that the oxygen tubing was changed. On 10/28/19 at 12:08 PM found the oxygen tubing coming from adapter on the humidifier bent at 90 degree angle. Licensed Practical Nurse (LPN) #96 entered Resident #57's room and confirmed the tubing was bent. and changed the tubing and humidifier. When asked when the tubing and bubble jugs are changed LPN #96 stated that they were changed on night shift once per week. No dates or identification to show when tubing and/or humidifier had been changed were present on the tubing and/or bubble jug. In an interview with the Director of Nursing (DON), on 10/29/19 at 1:03 PM, the DON stated that the oxygen tubing and bubble jug should have been dated when changed. In addition, the DON stated that there was no evidence the facility could provide to confirm the oxygen tubing and/or bubble jug had been changed as stated in the policy and procedure.",2020-09-01
749,CORTLAND ACRES NURSING HOME,515063,39 CORTLAND ACRES LANE,THOMAS,WV,26292,2019-10-30,883,D,0,1,4UQE11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to implement a pneumococcal vaccine according to the Center of Disease Control and Prevention (CDC) guidelines. This is true for one (1) of five (5) immunization record review. Resident identifier: Resident #68. Facility census 89. Finding includes: a) Resident #68 Records reveal Resident #68 received valent pneumococcal conjugate vaccine (PCV13) on 06/08/17. There no evidence the resident was offered the valent pneumococcal [MEDICATION NAME] vaccine (PPSV23). The CDC guidelines recommend giving the second pneumococcal vaccination in one year after giving the first vaccine. The facility pneumococcal vaccine policy directs the facility to the pneumococcal vaccines according to CDC guidelines. On 10/29/19 at 4:15 PM Registered nurse #70 agreed the facility failed to offer the Resident #68 the PPSV23 one year after giving the PCV13.,2020-09-01
750,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2017-01-26,253,E,0,1,4DYT11,"Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services for seven (7) of thirty (30) rooms observed during Stage 1 of the Quality Indicator Survey (QIS). The cosmetic imperfections included stained bathroom floor tiles, a scraped wall, a damaged wardrobe, a corroded facet, rusted raised toilet seats and missing anti-skid strips. Room identifiers: #102, #110, #202, #210, #307, #311, and #406. Facility census: 90. Findings include: a) Cosmetic imperfections --Room 102 observed on 01/24/17 at 8:33 a.m., had a blue stain on the bathroom floor tiles. --Room 110 observed on 01/24/17 at 8:23 a.m., had a wall with punctures behind bed and scratches and scuffed areas on the wardrobe. --Room 202 observed on 01/23/17 at 3:44 p.m., had missing and damaged anti-skid strips in the bathroom. --Room 210 observed on 01/24/17 at 8:34 a.m., had a corroded bathroom facet and a rusted raised toilet seat. --[RM #] observed on 01/24/17 at 8:18 a.m., had blue stains on the bathroom floor tiles and a rusted raised toilet seat. --Room 311 observed on 01/24/17 at 9:44 a.m., had stained bathroom tiles. --Room 406 observed on 01/23/17 at 3:33 p.m., had a privacy curtain with missing hooks and missing and damaged anti-skid strips in the bathroom. b) Interview with Maintenance Supervisor On 01/26/17 at 10:57 a.m., the Maintenance Supervisor verified the scraped wall, damaged wardrobe, missing and damaged anti-skid strips, stained bathroom floor tiles, corroded facet, and the rusted raised toilet seats needed to be cleaned, repaired or replaced.",2020-09-01
751,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2017-01-26,280,D,0,1,4DYT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and staff interview, the facility failed to revise a care plan for one (1) of twenty-one (21) sample care plans reviewed for dental status. A care plan was not updated after the medication [MEDICATION NAME] was discontinued. Resident identifier: #1. Facility census: 90. @ Findings include: @ a) Resident #1 A review of Resident #1's care plan on 01/24/17 at 2:00 p.m., revealed the resident had potential for oral discomfort related to dental status as evidence by missing and carious teeth. The care plan intervention was for the resident to use [MEDICATION NAME] gel 10% one (1) application orally every six (6) hours as needed for toothache. This intervention was initiated on 02/23/16. @ A review of the (MONTH) (YEAR)'s physician order on 01/24/17 at 2:05 p.m. for Resident #1 found no physician orders for [MEDICATION NAME] gel 10% every six (6) hours as needed for toothache. In an interview with minimum data set coordinator #63 on 01/24/17 at 3:20 p.m., reviewed Resident #1's record and found the [MEDICATION NAME] Gel 10% was discontinued on 06/29/16. Employee #63 stated, The [MEDICATION NAME] gel was discontinued, and the care plan never was updated to reflect this change.",2020-09-01
752,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2017-01-26,323,D,0,1,4DYT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to monitor neuro checks for a resident who had fallen and hit their head on two (2) different occasions. This practice has the potential to affect more than an isolated number of residents. Resident identifier: #61. Census: 90 Findings include: On 01/26/17 at 9:14 a.m., review of records revealed the resident had fallen on 12/21/16 and 01/03/17, both times hitting her head. A fall report dated 12/21/16, revealed Resident #61 fell to the floor and struck her forehead on the floor. The resident was sent to the emergency room for evaluation. Record showed vital signs were taken once right after the fall, with no mention of neuro checks. When the resident returned to the facility from the emergency room visit, a nurse's note revealed neuro checks were within normal limits. After the one entry there is no other mention or reference neuro checks were done. Review on 01/26/17 at 9:34 a.m., of a fall report dated 01/03/17, revealed Resident #61 fell to her knees and hit her head on the treatment cart. The record showed light red area noted to the resident's forehead. No evidence neuro checks were done were found in the records. An interview with the director of nurses (DON) on 01/26/17 at 11:13 a.m., revealed when a resident falls and hits their head, neuro checks should be done for 72 hours until the resident is stable or the physician discontinues the neuro checks. The DON stated neuro checks should be done every fifteen (15) minutes times four (4); then every thirty (30) minutes times four (4); then every hour times four (4); then every two (2) hours times four (4); then every four (4) hours times four (4) for the remaining 72 hours the resident is to be monitored. According to the DON, staff was to monitor and record neuro checks and place the results in the resident's chart. The DON was unable to find any evidence, in the resident's chart or electronic record, neuro checks had been performed either time the resident fell and hit their head on 12/21/16 or 01/03/17. The DON could not find an order either time to discontinue neuro checks. The DON agreed staff should have monitored the resident and obtained neuro checks as per policy or obtained a physician's orders [REDACTED].>On 01/26/17 at 11:26 a.m., review of facility's Fall Policy (NRC-NPSG-006), revealed, The facility will implement neuro checks any time a resident hits his/her head and/or if not known if the resident hit his/her head. Neuro checks will be completed up to 72 hours after the fall and/or until stable and discontinued via physician's orders [REDACTED].>",2020-09-01
753,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2017-01-26,371,E,0,1,4DYT11,"Based on observation and staff interview with the dietary manager, the facility failed to maintain sanitary condition. Equipment needed cleaned, personal items stored improperly in the food service area and food storage container lid was broken and not sealed properly was observed. This practice has the potential to affect more than a limited number of residents who are served food from this central location. Census: 90. Findings include: a) During the initial dietary tour with the dietary manager on 01/23/17 at 10:10 a.m., the following issues were noted: 1. Drip pans located under the range top were found to have an accumulation of food debris and were in need of cleaning. 2. The plastic bin which contained flour was noted to have a lid that was broken and did not seal as it should. This could allow vermin and debris to get into the container easily. 3. An employee's personal item was found stored on top of the flour bin which was located in the food service area of the dietary department. Personal items are to be stored in a separate location away for food area. These items were verified with the dietary manager at the time of the tour.",2020-09-01
754,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2017-01-26,441,D,0,1,4DYT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to implement practices designed to prevent the development and transmission of disease and infection and/or cross-contamination. A nurse failed to clean and sanitize a stethoscope, after using it to check the placement of a gastrostomy tube ([DEVICE]) for a resident with influenza symptoms, during Medication Pass of the Quality Indicator Survey (QIS). This practice had the potential to affect more than a limited number of residents in the facility. Resident identifier: #119. Census: 90 Findings Include: a) Resident #119 Observation of licensed practical nurse (LPN) #14 administering medication to Resident #119, on 01/25/17 at 2:40 p.m., revealed the LPN laid a stethoscope on the resident's bed without a barrier, and then placed it back on the medication cart. The LPN used the stethoscope to check the placement of the resident's [DEVICE] prior to giving medication via the [DEVICE]. The stethoscope was laid with the flat surface of the stethoscope's bell directly on the resident's bed. When the LPN was finished giving the medication she placed the stethoscope back onto the medicine cart, without cleaning or sanitizing it, and rolled the cart to another hall. During the time of the QIS there was an influenza outbreak at the facility. The LPN was asked if Resident #119 was showing signs or symptoms of influenza, and LPN revelaed she was showing signs and symptoms of infuenza. An interview with LPN #14, on 01/25/17 at 2:40 p.m., revealed LPN #14 agreed the stethoscope should have been cleaned and sanitized prior to taking it out of Resident #119's room and placing it back onto the medicine cart. The LPN cleaned the stethoscope after surveyor intervention. The DON was in the hall and was informed of the incident. The DON agreed that it was a breach in infection control principals and LPN#14 should have cleaned and sanitized the stethoscope before it could be used for any other resident.",2020-09-01
755,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2017-01-26,502,D,0,1,4DYT11,"**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 was provided services as ordered by the physician. The facility did not ensure physician's orders [REDACTED]. Resident #18's [MEDICAL CONDITION] panel, a laboratory (lab) test, was not obtained as ordered by the physician. Resident identifier: #18. Facility census: 90. Findings include: a) Resident #18 A review of the medical record on 01/24/17 at 1:53 p.m., revealed on 08/24/16 the Pharmacist recommended laboratory (lab) work to monitor the resident's [MEDICAL CONDITION] level and the physician accepted the recommendation on 09/04/16 to have a [MEDICAL CONDITION] panel completed. On 01/25/17 at 8:15 a.m., the Director of Nursing (DON) verified the [MEDICAL CONDITION] panel the physician had ordered on [DATE] for Resident #18 had not been completed.",2020-09-01
756,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2018-03-22,550,E,0,1,RG3511,"Based on observation, staff interview and policy review, the facility failed to promote dignity for four of 23 residents by posting personal care information and instructions above resident beds in a viewable manner for Residents #43, #71, #90 and #92. Resident identifiers: #43, #71, #90 and #92. Facility census: 96. Findings included: a) Resident #43 On 03/21/18, at 8:18 AM, a sign was observed above Resident#43's bed noting the resident was hard of hearing and to speak in left ear. b) Resident #71 On 03/19/18, at 1:05 PM, a sign was observed above Resident # 71's bed noting to give the resident medication from right side and place spoon on right side of her mouth. c) Resident #90 On 03/19/18 at 11:03 AM, a sign was observed above Resident #90's bed noting not use pullups on the resident because he breaks out from them. An additional observation on 03/20/18 revealed the sign still present in viewable sight above the resident's bed. d) Resident #43 On 03/21/18 at 820 AM, a sign was posted above the bed for Resident #92 noted no blood pressure, blood draw or injections to the left arm. e) Interviews An interview with the Administrator on 03/20/18 at 3:05 PM revealed signs are not to be above resident's beds disclosing personal care information. During an interview with the Administrator and Director of Nursing on 03/21/18 at 8:18 AM, acknowledged the signs were posted above the beds of Resident #43, #92 and #71 and stated the signs should not be posted in this manner. A review of the facility policy for Resident Records on 03/21/18, at 3:20 PM, revealed PVNRC will keep confidential all information contained in the resident's records.",2020-09-01
757,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2018-03-22,558,D,0,1,RG3511,"Based on observation, resident interview, and staff interview, the facility failed to provide services with reasonable accommodation for residents. Resident #248 and #250's over the bed light cords were not long enough to be easily reached by the residents. This practice affected two (2) of twenty-three (23) residents observed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #248 and #250. Facility census: 96. Findings included: a) Resident #248 An observation of the Resident, on 03/19/18 at 1:30 PM, revealed the Resident's over the bed light cord was approximately three inches long. An interview with the Resident, on 03/19/18 at 1:35 PM, revealed the Resident could not reach the over the bed light cord without having to get up out of bed. The Resident stated the light was hard to turn on and off with the short cord. The Resident stated the staff turn has to turn the light off and on. The resident stated she had reported the light several times to the aides. b) Resident #250 An observation of the Resident, on 03/21/18 at 2:45 PM, revealed the Resident's over the bed light cord was approximately three inches long. An interview with the Resident, on 03/21/18 at 2:48 PM, revealed the Resident could not reach the over the bed light cord. An interview with the Administrator, on 03/21/18 at 3:10 PM, revealed the over the bed light cords had extenders which had fallen off. The Administrator stated she would ensure the cords were fixed immediately.",2020-09-01
758,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2018-03-22,583,E,0,1,RG3511,"Based on observation and staff interview, the facility failed to ensure personal privacy and confidentiality of health information for residents. Personal identifiers including resident's names, medications, diagnosis, and physicians were listed on discarded pharmacy labels. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #30 and #250. Facility census: 96. Findings included: a) Resident #30 An observation of the 200 Hall, on 03/20/18 at 8:10 AM, revealed one (1) visible empty medication card/packet, with the pharmacy label still attached, in the trash can of the medication cart. The resident's medication packet contained the following information: -Name -Medication -Diagnosis -Physician An interview with Licensed Practical Nurse (LPN) #33, on 03/20/18 at 8:12 AM, revealed any resident information should be removed from the pharmacy labels before throwing them away. The LPN stated the night shift nurses usually throw the medication cards away without removing the resident information. b) Resident #250 An observation of the 400 Hall, on 03/20/18 at 8:20 AM, revealed one (1) visible empty medication card/packet, with the pharmacy label still attached, in the trash can of the medication cart. The resident's medication packet contained the following information: -Name -Medication -Diagnosis -Physician An interview with Registered Nurse (RN) #3, on 03/20/18 at 8:23 AM, revealed she usually takes a black marker and blackens out the resident information before discarding the pharmacy labels. An interview with the Director of Nursing (DON), on 03/21/18 at 11:30 AM, revealed the nurses are supposed to remove the pharmacy labels or mark over any resident information on the medication cards before discarding them.",2020-09-01
759,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2018-03-22,584,E,0,1,RG3511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide maintenance services for eleven (11) of forty-three (43) rooms observed during the Long Term Care Survey Process (LTCSP). The issues identified included resident's rooms and bathrooms with scratched doors and walls, missing paint, loose wallpaper, loose rubber base trim, rusted equipment, and stained floors. Room identifiers: #103, #104, #203, #204, #305, #309, #311, #405, #408, #409, and the Main Dining Room. Facility census: 96. Findings include: a) Observations The following observations were made on 03/19/18, 03/20/18, and 03/21/18 during the LTCSP: -room [ROOM NUMBER]-The bathroom had stains around the base of toilet. The rubber base trim was loose in the bathroom. -room [ROOM NUMBER]-The bathroom door was scratched. The wall beside the sink was stained. -room [ROOM NUMBER]-The lift seat in the bathroom was soiled. -room [ROOM NUMBER]-The plaster behind the sink was in disrepair. -room [ROOM NUMBER]-The bathroom door was scratched -room [ROOM NUMBER]-The wall beside Bed-B was scratched. -room [ROOM NUMBER]-The floor was stained by the window -room [ROOM NUMBER]-The wall beside Bed-B was missing paint. The seal around the bathroom sink was rusted. -room [ROOM NUMBER]-The wall behind the sink was missing paint. The bathroom had a rusted shower/water hose. The paint was missing around the base of the wall in the bathroom. -room [ROOM NUMBER]-The wall in the bathroom beside the toilet was discolored green. The rubber base trim was coming off the wall in the bathroom. -Main Dining Room-The wallpaper was loose in several areas on the wall beside the exit door to the outside. b) Interview An interview with the Maintenance Director, on 03/22/18 at 9:45 AM, revealed weekly rounds are completed on the rooms. The Maintenance Director stated the repairs on the resident rooms are difficult to keep up with. The Maintenance Director stated even if I fixed all of the rooms today they would be torn back up next week.",2020-09-01
760,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2018-03-22,585,D,0,1,RG3511,"Based on record review, resident and staff interview and review of the grievance file, the facility failed to initiate and document findings for a grievance for 1 of 4 grievances reviewed. Resident identifier: #90. Facility census: 96. Findings included: a) Resident #90 An interview with Resident #90, on 03/19/18 at 1:49 PM, revealed the resident had seventeen (17) dollars missing and had complained to management about it. A review of the medical record revealed no documentation of Resident #90's complaint being acknowledged, investigated or findings documented of an investigation. An interview with the Administrator and Social Worker, on 03/20/18, at 02:20 PM and 03:05 PM, revealed the facility practice was if something was missing but was found, nothing was documented. A review, of the facility policy and procedure for Grievances dated 11/21/16, revealed Upon receiving the grievance/complaint the Social Service Director or designee will investigate the grievance and report findings to the administrator within five days as possible. The facility will maintain evidence demonstrating the results of all grievances for a period of no less than 3 years from the issuance of the grievance decision.",2020-09-01
761,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2018-03-22,657,D,0,1,RG3511,"**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 two (2) of twenty-three (23) comprehensive care plans had been reviewed and revised by the interdisciplinary team. This practice involved needed revisions for the floating of heels. Resident identifiers: #93 and #248. Facility census: 96. Findings included: a) Resident #93 An observation of the Resident, on 03/19/18 at 2:20 PM, revealed the resident's heels were not floated while lying in bed. An observation of the Resident, on 03/21/18 at 7:55 AM, revealed the resident's feet were not floated while lying in bed. An interview with the Resident, on 03/21/18 at 7:58 AM, revealed the staff does not float her heels. The Resident stated they used to but not anymore. An interview with Certified Nursing Assistant (CNA) #13, on 03/21/18 at 8:05 AM, revealed that she does not float the resident's heels. The CNA stated the resident usually ends up removing the pillow herself because she is up a lot. The CNA stated she has not floated the resident's heels for weeks. The CNA stated she had reported the resident's behavior to the nurse several times. A review of the Resident's physician orders, on 03/21/18 at 8:10 AM, revealed the Resident had an order, dated 02/21/18, to Keep heels elevated at all times while in bed-check every shift. A review of the Resident's Care Plan was conducted on 03/21/18 at 9:00 AM. The Care Plan, with an initiation date of 03/06/18, contained the focus of At risk for pressure ulcer development related to impaired mobility with the intervention Keep bilateral heels elevated, check compliance every shift. b) Resident #248 An observation of the Resident, on 03/21/18 at 7:55 AM, revealed the resident's heels were not floated while lying in bed. An interview with Certified Nursing Assistant (CNA) #13, on 03/21/18 at 8:08 AM, revealed that she does not float the resident's heels. The CNA stated they do not need them floated anymore because they are independent. A review of the Resident's physician orders, on 03/21/18 at 8:15 AM, revealed the Resident had an order, dated 03/02/18, to Keep heels elevated at all times while in bed-check every shift. A review of the Resident's Care Plan was conducted on 03/21/18 at 9:05 AM. The Care Plan, with an initiation date of 03/15/18, contained the focus of At risk for pressure ulcer development related to advancing age and skin fragility with the intervention Keep bilateral heels elevated, check compliance every shift. An interview with the Director of Nursing (DON), on 03/21/18 at 10:30 AM, revealed Resident #93 and #248's heels were only floated when they were first admitted to the facility. The DON stated their heels are no longer being floated because the residents are frequently up and moving. The DON stated the physician orders [REDACTED].",2020-09-01
762,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2018-03-22,684,D,0,1,RG3511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and record review, the facility failed to float residents' heels as ordered by the physician. This practice affected two (2) of twenty-three (23) residents reviewed. Resident identifiers: #93 and #248. Facility census: 96. Findings included: a) Resident #93 An observation of the Resident, on 03/19/18 at 2:20 PM, revealed the resident's heels were not floated while lying in bed. An observation of the Resident, on 03/21/18 at 7:55 AM, revealed the resident's feet were not floated while lying in bed. An interview with the Resident, on 03/21/18 at 7:58 AM, revealed the staff does not float her heels. The Resident stated they used to but not anymore. An interview with Certified Nursing Assistant (CNA) #13, on 03/21/18 at 8:05 AM, revealed that she does not float the resident's heels. The CNA stated the resident usually ends up removing the pillow herself because she is up a lot. The CNA stated she has not floated the resident's heels for weeks. The CNA stated she had reported the resident's behavior to the nurse several times. A review of the Resident's physician orders, on 03/21/18 at 8:10 AM, revealed the Resident had an order, dated 02/21/18, to Keep heels elevated at all times while in bed-check every shift. A review of the Resident's Care Plan was conducted on 03/21/18 at 9:00 AM. The Care Plan, with an initiation date of 03/06/18, contained the focus of At risk for pressure ulcer development related to impaired mobility with the intervention Keep bilateral heels elevated, check compliance every shift. b) Resident #248 An observation of the Resident, on 03/21/18 at 7:55 AM, revealed the resident's heels were not floated while lying in bed. An interview with Certified Nursing Assistant (CNA) #13, on 03/21/18 at 8:08 AM, revealed that she does not float the resident's heels. The CNA stated they do not need them floated anymore because they are independent. A review of the Resident's physician orders, on 03/21/18 at 8:15 AM, revealed the Resident had an order, dated 03/02/18, to Keep heels elevated at all times while in bed-check every shift. A review of the Resident's Care Plan was conducted on 03/21/18 at 9:05 AM. The Care Plan, with an initiation date of 03/15/18, contained the focus of At risk for pressure ulcer development related to advancing age and skin fragility with the intervention Keep bilateral heels elevated, check compliance every shift. An interview with the Director of Nursing (DON), on 03/21/18 at 10:30 AM, revealed Resident #93 and #248's heels were only floated when they were first admitted to the facility. The DON stated their heels are no longer being floated because the residents are frequently up and moving. The DON stated the physician orders [REDACTED].",2020-09-01
763,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2018-03-22,689,E,0,1,RG3511,"**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. Three (3) medication carts were unlocked and a shower room cabinet contained hygiene products and razors accessible to anyone. This practice had the potential to affect more than a limited number of residents. Facility census: 96. Findings included: a) Medication Carts A random observation of the 300 Hall, on 03/22/18 at 7:25 AM, revealed the Exam Room's door was propped open. The room contained three (3) medication carts which were all unlocked, unattended, and out of sight of any staff from 7:25 AM until 7:30 AM. The carts contained medications for the 200 and 300 Hall residents. An interview with Licensed Practical Nurse (LPN) #31, on 03/22/18 at 7:30 AM, revealed the medication carts should always be locked when not in use or in sight of a nurse. The LPN stated the Exam Room should also always be locked. b) Shower Room An observation of the 400 Hall, on 03/20/18 at 9:30 AM, revealed the shower room was not locked. The cabinet in the shower room was unlocked. The cabinet contained the following items: -Three (3) capped shaving razors -Three (3) containers of [MEDICATION NAME] Pro-Shaving Cream with the warning Keep out of reach of children -One (1) container of [MEDICATION NAME] Topical Powder -One (1) tube of Extra Protective Cream with the warning Keep out of reach of children-If swallowed get medical help or contact a Poison Control Center immediately -One (1) container of [NAME]ons Baby Powder with the warning Avoid contact with eyes-Keep away from face to avoid inhalation An interview with the Administrator, on 03/20/18 at 11:00 AM, revealed the cabinets in the shower rooms should always be locked to prevent the residents from having access to the items inside.",2020-09-01
764,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2018-03-22,695,E,0,1,RG3511,"Based on observation, staff interview, and policy review, the facility failed to provide respiratory care consistent with the professional standards of practice. Residents' oxygen supplies were not dated and stored in a bag while not in use. This practice affected four (4) of five (5) residents reviewed for respiratory care. Resident identifiers: #9, #38, #93, and #250. Facility census: 96. Findings included: a) Resident #93 An observation, on 03/19/18 at 12:45 PM, revealed the Resident's oxygen tubing was not dated. The resident was receiving oxygen via nasal cannula at the time of the observation. The oxygen tubing storage bag had a date but could not be easily read. Further observation, on 03/21/18 at 10:45 AM, revealed the Resident's oxygen tubing was not dated. The resident was receiving oxygen via nasal cannula at the time of the observation. b) Resident #250 An observation of the Resident's room, on 03/19/18 at 2:22 PM, revealed the Resident's oxygen tubing was lying on the floor and was not dated. The resident was out of the room at the time of the observation. There was not a dated oxygen tubing storage bag for the resident in the room. An interview with the Administrator, on 03/21/18 at 11:00 AM, revealed only the bag that the oxygen tubing is stored in is dated. The Administrator stated the oxygen supplies are supposed to be changed weekly and kept in a bag while not in use. The Administrator stated if the storage bag is missing or not dated there is no way to ensure the last time the oxygen was changed. A review of the facility's policy, on 03/21/18 at 11:30 AM, titled Changing of Respiratory Supplies with a revision date of 11/17, revealed the oxygen supplies are to be changed every week and maintained in a bag while the facility will date the respiratory supplies weekly.",2020-09-01
765,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2018-03-22,757,D,0,1,RG3511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to address non-pharmacological interventions for ordered pain medications. This practice affected one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #80. Facility census: 96. Findings included: a) Resident #80 A review of the physician orders, on 03/21/18 at 11:35 AM, revealed the following two orders for pain medication since the resident was admitted on [DATE]: -Tylenol 650 milligrams, by mouth, every 4 hours as needed for pain, with a start date of 03/27/14. -Tylenol (8 Hour Arthritis-Extended Release) 650 milligrams, as needed for pain, with a start date of 09/22/17. A review of Resident #80's Care Plan was conducted on 03/21/18 at 1:35 PM. The Care Plan, with a review date of 09/08/17, contained no non-pharmacological interventions for the pain medications. Further review of the medical record, on 03/22/18 at 8:25 AM, revealed no non-pharmacological interventions were documented. An interview with the Director of Nursing (DON), on 03/22/18 at 8:45 AM, revealed no non-pharmacological interventions for pain medication were in place for Resident #80. The DON stated non-pharmacological interventions should have been on the care plan and in place for the ordered pain medications.",2020-09-01
766,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2018-03-22,804,E,0,1,RG3511,"Based on observation, staff interview, resident interview and results of test tray temperatures, the facility failed to provide foods served at palatable temperatures. This was evident for more than a limited number of residents who receive foods served from this central location. Census: 96. Findings included: a) During confidential interviews with residents in the dining room at lunch on 03/19/18, they expressed concern that the dish machine had been out of service for some time and the facility was having to use disposable dishware and silverware. The disposable silverware also made it hard to cut some of the food items. This did not hold the temperature of the food very well causing it to not be palatable. Foods in the dining room would be hot at times because food is served straight from the kitchen area into the room. If you ate in your room foods did not stay warm enough. b) Interview with staff on 03/19 and 3/20/18 it was found the dishmaching was not fully operational since sometime in November. The machine would be repaired and then break down again. Disposable dish and silverware was being used. c) Food temperature evaluations were conducted on 03/21/18 at lunch on the 300 hall where surveyors heard the most comments about food. The temperatures were not found to be at acceptable levels required by state standards. The turkey and/or taco salad meat was found to not be a palatable temperatures. Additinally green beans were not warm enough.",2020-09-01
767,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2018-03-22,880,E,0,1,RG3511,"Based on observation and staff interview, the facility failed to ensure a treatment cart was kept clean. This practice had the potential to affect an unlimited number of residents. Facility census: 96. Findings included: a) Treatment cart An observation of the treatment cart, on 03/21/2018 at 12:00 PM revealed the exterior surfaces of the treatment cart with dirt, dust, and splash marks on the sides of the cart and the bottom rail. An interview with Treatment Nurse, RN#77 on 03/21/2018 at 12:05 PM revealed that a new treatment cart is coming from pharmacy and that the top of the cart is cleansed with sanitizer. An interview with Director of Nursing (DON) #21 on 03/21/2018 at 12:15 PM revealed there is not a policy for cleaning the treatment cart.",2020-09-01
768,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2018-03-22,908,F,0,1,RG3511,"Based on observation, review of documentation and interviews with staff and residents it was found the facility dish machine had not be fully operational since November, (YEAR). The machine was not in operation during the survey and disposable silverware and dishware was being used to serve resident food. This procedure has the potential to affect more than a limited number of residents who are served meals from this central location. Facility census: 96. Findings includes: a) During the initial tour of the dietary department on 03/19/18 prior to lunch it was discovered the dishwash machine was not in service. Discussion with the dietary manager revealed the machine had been inoperable off and on since (MONTH) (YEAR). b) While doing confidential resident interviews during lunch time in the dining room residents expressed that the dishwash machine had been out of operation since (MONTH) or (MONTH) (YEAR). Dietary staff was having to use disposable dishware and cutlery. The food was sometimes hard to cut with the plastic silverware and disposable plates did not hold the heat so food was not kept warm. c) A discussion with the administrator on 03/19 /18 in the afternoon, revealed they dishwash machine had been broken in (MONTH) (YEAR), and was repaired Shortly after it was out of service again and needed more repair. On 03/20/18 the administrator submitted a repair document from the dishmachine service staff stated the dishmachine motor was in poor shape and needed a new pump motor. The facility got two quotes on a new unit and submitted this to purchasing (MONTH) (YEAR). The purchasing department did not give approval for the new unit to be bought until late (MONTH) (YEAR). This was over a month timeframe. During this time the faciily still had to use disposable eating utensils and plates which resulted in the food not always being hot and palatable enough.",2020-09-01
769,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2018-03-22,925,E,0,1,RG3511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain an environment free from pests. Resident rooms and a hallway were observed on multiple occasions to have gnats. This practice affected three (3) of forty-three (43) rooms and the 200 Hallway. Room identifiers: #105, #203, #204, and the 200 Hallway. Facility census: 96. Findings include: a) Observation Multiple observations, on 03/19/18, 03/20/18, and 03/21/18, revealed the following resident rooms and areas had gnats present: -room [ROOM NUMBER] -room [ROOM NUMBER] -room [ROOM NUMBER] -200 Hallway b) Interview An interview with the Administrator, on 03/21/18 at 9:10 AM, revealed she too observed the gnats upon observation. The Administrator stated the gnats really cannot be prevented fully when the residents have food in their rooms. The Administrator stated she would contact the pest control company and have them taken care of immediately.",2020-09-01
770,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2019-05-01,550,D,0,1,7QRC11,"Based on observation, staff interview, and policy review, the facility failed to treat each resident with respect and dignity. Part of a resident's room was being used as a storage area for the facility and a partially dressed resident was receiving care in the hallway. This practice affected two (2) of twenty-nine (29) residents observed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #50 and #69. Facility census: 96. Findings included: a) Resident #69 An observation of the Resident, on 04/30/19 at 11:50 AM, revealed the Resident was in the Life Skills Room. The Life Skills area consists of two adjoining rooms. The first room, in which the Resident has to pass through to get to their bed and bathroom, was observed to have approximately ten (10) wheelchairs, an oxygen tank, a mechanical lift, and a weight scale stored in the room. There was just enough space for the Resident to get by the equipment to get in and out of their room. An interview with the Administrator, on 04/30/19 at 12:05 PM, revealed the Life Skills area was used as extra storage for the facility's equipment. The Administrator agreed it was not a dignified area for the Resident to be living in. The Administrator stated she would have the equipment emptied out of the room immediately. b) Resident #50 An observation on 04/29/19, at 11:10 AM revealed Resident #50 (R#50) seated in a reclining chair, in the hallway, outside of the 200 Hall shower room. R#50 was covered with a bath blanket that was tucked under the maxillae exposing her upper chest area. NA#2 was observed providing care. An interview, on 04/29/19, at 11:10 AM, with NA#2, revealed care was being provided in the hallway because of the shower room being stuffy. An interview, on 04/30/19 at 11:36 AM, with the Administrator, verified it was unacceptable for the resident to receive care in the hallway covered with a bath blanket and should have been dressed prior to leaving the shower room. A review of Policy NRC-RR-015, Dignity F557, effective 11/15/16, noted Residents shall be sufficiently covered when being taken to areas outside of their room.",2020-09-01
771,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2019-05-01,580,D,0,1,7QRC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to inform Resident #37's physician of blood sugar levels above the acceptable range. This was true for one (1) of twenty-nine residents reviewed in the sample. Resident identifier: #37. Facility census: 96 Findings included: On 04/30/19 at 3:30 PM, review of Resident #37's physician's orders [REDACTED]. --If blood sugar is 0 - 149 then no insulin required. --If Blood Sugar is less than 60 then call the physician. --If blood sugar is 150 - 200 inject 2 units of [MEDICATION NAME]. --If blood sugar is 201 - 250 inject 4 units of [MEDICATION NAME]. --If blood sugar is 251 - 300 inject 6 units of [MEDICATION NAME]. --If blood sugar is 301 - 350 inject 8 units of [MEDICATION NAME]. --If blood sugar is 351 - 400 inject 10 units of [MEDICATION NAME]. --If blood sugar is 401 - 450 inject 12 units of [MEDICATION NAME]. --If blood sugar is 451 - 999 inject 15 units of [MEDICATION NAME]. --If blood sugar is greater than 450 then call physician. Record review on 04/30/19 at 3:50 PM revealed Resident #37 had a blood sugar over 450 on 03/02/019, 03/04/19, 03/26/19, 03/29/19, 03/31/19, 04/03/19, 04/09/19, 04/13/19, and 04/19/19 (three incidents for this date) and the physician was not notified as ordered for these occurrences. During an interview on 05/01/19 at 8:20 AM, it was verified by the Administrator #7 and Director of Nursing #6 that the facility had no documentation to verify the physician had been notified of the blood sugar readings as ordered. Administrator #7 stated, It's not documented, I have no way of knowing if it was done or not. Director of Nursing #6, They (nursing staff) should have documented talking to the physician in the progress notes in the computer, but it's not there. At 10:05 AM on 05/01/19, Administrator #7 stated We (the facility) don't have a policy for notifying the physician of abnormal blood sugar readings, the only policy we have is on how to administer insulin.",2020-09-01
772,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2019-05-01,583,E,0,1,7QRC11,"Based on observation and staff interview, the facility failed to ensure the 100 Hall Nurse Report Sheets were covered in a manner that protected personal, medical, and health information. Personal identifiers including the resident's names, room numbers, medications, medical interventions, and treatments, were listed on the Nurse Report Sheets. This was a random observation. This practice affected more than a limited number of residents. Facility census: 96. Findings included: a) Observation An random observation during medication administration, on 05/01/19 at 7:45 AM, revealed Nurse Report Sheets were lying face up on a medication cart in the 100 Hallway. The Nurse Report Sheets contained information for twelve (12) Residents. The information on the sheet was visible for anyone in the hallway to see. The Nurse Report Sheets contained the following resident information: --Resident Names --Resident Room Numbers --Medications --Treatments --Behaviors b) Interview An interview with Registered Nurse (RN) #36, on 05/01/19 at 7:50 AM, revealed the Nurse Report Sheet should have been turned over or covered when she was not at the medication cart.",2020-09-01
773,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2019-05-01,584,E,0,1,7QRC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and record review, the facility failed to ensure a safe, clean, comfortable, and homelike environment for residents. Resident rooms were not in good repair, the dining service was not homelike, an oxygen filter was dirty, and water temperatures were too low for resident's receiving showers. This practice affected more than a limited number of residents. Resident identifiers: #5, #52, #62, #64 and #51. Room identifiers: #103, #203, #204, #301, #408, 300 Hall Shower Room, 400 Hall Shower Room, and 400 Hall Dining Room, Main Dining Room. Facility census: 96. Findings included: a) Environmental Issues The following observations were made during the LTCSP on 04/29/19 and 04/30/19: --room [ROOM NUMBER]-The fall mat is cracked in multiple places --room [ROOM NUMBER]-The floor behind the toilet is stained --room [ROOM NUMBER]-scrape on wall adjacent to sink on outside wall visible as you walk in --room [ROOM NUMBER]-The floor is stained around the base of the toilet. --room [ROOM NUMBER]-Holes in the wall beside Bed B. --room [ROOM NUMBER] Hall Shower Room-tiles are stained, and the walls are scratched. --room [ROOM NUMBER] Hall Dining/Vending Room-The counter by the sink is hooved up, plastic covering on counter separated from wooden base. --300 Hall Shower Room-Tile at drain stained black with gooey thick substance. An interview with the facility's Maintenance Supervisor (MS) #90, on 05/01/19 at 08:53 AM, revealed resident room checks are conducted monthly. The MS stated he would ensure all the issues found during the LTCSP would be fixed immediately. b) Low Temperature of Water During Resident Council Meeting on 04/29/19 at 2:39 PM, Resident # 62 stated that an ongoing concern was the cold showers they have been getting in the 300 Hall Shower Room. Resident #52 and Resident #64 agreed that the water in the 300 Hall Shower Room is too cold and is not comfortable enough for bathing. Resident #62 stated, It (cold water) freezes us to death in there (300 Hall Shower Room), we have told them (facility staff), but nothing's been done. During observation of 300 Hall Shower Room's hot water, in the presence of Registered Nurse (RN) # at 2:50 PM on 04/30/19, revealed the water coming out of the hand-held shower head used to bath residents to only be tepid warm to the touch. After allowing hot water to run for 5 minutes, a temperature reading of 99 degrees was obtained with surveyor thermometer and verified by RN #37. RN #37 agreed that the water temperature was too chilly to be comfortable for Residents to bath in. Immediately after obtaining the temperate reading, observation of inline mercury thermometer located on the hot water tank serving 300 Hall Shower Room revealed a reading of 100 degrees at this time. Observation on 05/01/19 at 08:28 AM in 300 Hall Shower Room revealed fluctuating water temperatures obtained by Maintenance Supervisor #90 to be from 99 degrees to 101 degrees. At the time these temperature readings were obtained, no showers had been given. Prior to water temperature checks, the inline thermometer on the hot water heater serving the 300 Hall Shower Room read 100 degrees. After running the water in the shower for 5 minutes, the inline thermometer on water heater reading dropped to 98 degrees. MS #90 stated we like to keep it below 110 per regulations, I hate to get too hot. We (the facility) turned it down because we got into trouble for it (hot water) being too hot. The MS #90 also stated, On shower days, the hot water does good to keep up, it's a struggle to keep it warm when they shower a lot of residents in a row. At 8:27 AM on 05/01/19 during an interview Registered Nurse (RN) #81 stated, The residents complain to me all the time about the water being too cold in the shower room on 300 hall. I often go in there with them since I am treatment nurse to observe their wounds and they (Residents) say the water is too cold all the time. On 05/01/19 at 09:56 AM Administrator #7 stated, We do not have a policy on water temperatures, the facility just uses life safety guidelines. During an interview with Nurse Aide #67 at 10:00 AM on 05/01/19, NA #67 stated, The water does get cold in shower room on 300 hall after it runs a while, the Residents complain about it all the time. c) Dining During an observation of the lunch meal on 04/29/19 at 11:55 AM, it was noted that residents were not provided with reusable drinking glasses unless they required a special adaptive cup. For those residents not requiring adaptive drinkware, staff were observed stabbing straws into the foil lids of juice cups and placing straws down into soda cans. A handful of residents were observed to have disposable Styrofoam cups for their drinks. During an interview on 04/29/19 at 12:12 PM, Food Service Supervisor (FSS) #92 said that this practice of placing straws in juice cups and soda cans and using other disposable drinkware was typical for the facility. The facility's Administrator was notified of the above information on 04/29/19 at 1:18 PM. During an additional observation of lunch in the dining room on 04/30/19 at 11:43 AM, staff asked residents about their preferences for drinkware. Some residents chose to have a straw placed directly into a disposable cup or can, but many residents opted for reusable drinkware when given the option, which made the dining room appear more home-like than it had the previous day. d) Oxygen mixer A random observation on 04/29/19 at 11:30 AM, found two (2) oxygen filters on Resident (R) #51's Invacare oxygen mixer covered in white lint or dust. During an interview on 04/29/19 at 3:30 PM, Registered Nurse (RN) #36 confirmed the oxygen mixer filters needed replaced on R #51's oxygen machine. e) Fall mat On 04/29/19 01:34 PM, R #5's fall mat along his bed was found with multiple cracks and tears. Nurse Aide #69 was present and agreed the matt needed replaced. The Director of Nursing (DON) viewed R #5's fall mat at 2:30 PM on 04/30/19 and confirmed the mat was unsanitary and should be replaced.",2020-09-01
774,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2019-05-01,656,D,0,1,7QRC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure the implementation of individualized care plan interventions related to pressure ulcer risks. Floating of heels, for residents identified as a high pressure ulcer risk, were not implemented as directed by their care plans. This practice affected three (3) of twenty-nine (29) residents observed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #21, #57, and #61. Facility census. 96. Findings included: a) Resident #21 An observation of the Resident, on 04/30/19 at 8:38 AM, revealed the Resident was in bed. Their heels were not floated. A record review, 04/30/19 1:06 PM, revealed the physician order [REDACTED]. Further review of the Resident's medical record, on 04/30/19 at 1:15 PM, revealed a Care Plan with the focus Resident is at risk for pressure ulcer development related to impaired mobility and incontinence with the intervention of keep bilateral heels elevated, check compliance every shift. The Care Plan was dated 02/04/19. An interview with Registered Nurse (RN) #34, on 04/30/19 at 1:20 PM, revealed the Resident should have their heels floated anytime they are in bed. b) Resident #57 Observations, on 04/29/19 at 11:15 and 2:22 PM, revealed the Resident was in bed. The Resident's heels were not floated on either observation. An interview with Nurse Aide (NA) #78, on 04/29/19 at 2:25 PM, revealed the Resident's heels do not need floated. The NA stated he never floats the Resident's heels. A record review, on 04/30/19 1:24 PM, revealed the physician order [REDACTED]. Further review of the Resident's medical record, on 04/30/19 at 1:30 PM, revealed a Care Plan with the focus Resident is at risk for pressure ulcer development related to incontinence and decreased mobility with the intervention Keep bilateral heels elevated, check compliance every shift. The Care Plan was dated 03/14/19. c) Resident #61 Observations, on 04/29/19 at 2:00 PM and 3:00 PM, revealed the Resident was in bed. Their heels were not floated on either observation. An interview with Nurse Aide (NA) #78, on 04/29/19 at 3:05 PM, revealed the Resident's heels do not need floated. The NA stated he never floats the Resident's heels. A record review, on 04/30/19 at 1:47 PM, revealed the physician order [REDACTED]. Further review of the Resident's medical record, on 04/30/19 at 1:56 PM, revealed a Care Plan with the focus Resident is at risk for pressure ulcer development with the intervention Keep bilateral lower extremities on pillows at all times in bed to float heels. The Care Plan was dated 09/28/18.",2020-09-01
775,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2019-05-01,684,E,0,1,7QRC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review, the facility failed to ensure that five (5) of twenty-nine (29) residents reviewed during the Long Term Care Survey Process (LTCSP) received care and treatment in accordance with physician orders [REDACTED]. Physician orders [REDACTED]. Resident identifiers: #21, #57, #61, #67, and #37. Facility census: 96. Findings included: a) Resident #21 An observation of the Resident, on 04/30/19 at 8:38 AM, revealed the Resident was in bed. Their heels were not floated. A record review, 04/30/19 1:06 PM, revealed the physician order [REDACTED]. Further review of the Resident's medical record, on 04/30/19 at 1:15 PM, revealed a Care Plan with the focus Resident is at risk for pressure ulcer development related to impaired mobility and incontinence with the intervention of keep bilateral heels elevated, check compliance every shift. The Care Plan was dated 02/04/19. An interview with Registered Nurse (RN) #34, on 04/30/19 at 1:20 PM, revealed the Resident should have their heels floated anytime they are in bed. b) Resident #57 Observations, on 04/29/19 at 11:15 and 2:22 PM, revealed the Resident was in bed. The Resident's heels were not floated on either observation. An interview with Nurse Aide (NA) #78, on 04/29/19 at 2:25 PM, revealed the Resident's heels do not need floated. The NA stated he never floats the Resident's heels. A record review, on 04/30/19 1:24 PM, revealed the physician order [REDACTED]. Further review of the Resident's medical record, on 04/30/19 at 1:30 PM, revealed a Care Plan with the focus Resident is at risk for pressure ulcer development related to incontinence and decreased mobility with the intervention Keep bilateral heels elevated, check compliance every shift. The Care Plan was dated 03/14/19. c) Resident #61 Observations, on 04/29/19 at 2:00 PM and 3:00 PM, revealed the Resident was in bed. Their heels were not floated on either observation. An interview with Nurse Aide (NA) #78, on 04/29/19 at 3:05 PM, revealed the Resident's heels do not need floated. The NA stated he never floats the Resident's heels. A record review, on 04/30/19 at 1:47 PM, revealed the physician order [REDACTED]. Further review of the Resident's medical record, on 04/30/19 at 1:56 PM, revealed a Care Plan with the focus Resident is at risk for pressure ulcer development with the intervention Keep bilateral lower extremities on pillows at all times in bed to float heels. The Care Plan was dated 09/28/18. d) Resident #67 Review of the medical record for Resident #67 (R#67), revealed no bowel movements occurring from 04/12/19 to 04/19/19. Review of the physician's orders [REDACTED]. --Milk of Magnesia (MOM) 30 milliliters if no BM after 3 days --If MOM ineffective, give [MEDICATION NAME] RS the following day for no results --If [MEDICATION NAME] RS ineffective, give Fleets enema for severe constipation, if ineffective, notify physician There was no indication that the MOM had been administered the resident after 3 days of R#67 not having a BM. The documentation on the Medication Administration Record [REDACTED]. Further review of the medical record revealed R#67 had no BM from 04/20/19 through 04/29/19 with no record of the BM Protocol being administered. An interview , on 04/30/19 at 02:42 PM, with RN#38, verified the standing orders for the BM Protocol was in place but no indication it had been implemented as ordered by the physician, once the resident went 3 days without having a BM. An interview, on 05/1/19 at 08:12 AM, with RN#38 and the Director of Nursing, verified there were no additional information found and verified the bowel movement (BM) Protocol had not been implemented in accordance with physician's orders [REDACTED]. e) Resident #37 On 04/30/19 at 3:30 PM, review of Resident #37's physician's orders [REDACTED]. --If blood sugar is 0 - 149 then no insulin required. --If Blood Sugar is less than 60 then call the physician. --If blood sugar is 150 - 200 inject 2 units of [MEDICATION NAME]. --If blood sugar is 201 - 250 inject 4 units of [MEDICATION NAME]. --If blood sugar is 251 - 300 inject 6 units of [MEDICATION NAME]. --If blood sugar is 301 - 350 inject 8 units of [MEDICATION NAME]. --If blood sugar is 351 - 400 inject 10 units of [MEDICATION NAME]. --If blood sugar is 401 - 450 inject 12 units of [MEDICATION NAME]. --If blood sugar is 451 - 999 inject 15 units of [MEDICATION NAME]. --If blood sugar is greater than 450 then call physician. Record review on 04/30/19 at 3:50 PM revealed Resident #37 had a blood sugar over 450 on 03/02/019, 03/04/19, 03/26/19, 03/29/19, 03/31/19, 04/03/19, 04/09/19, 04/13/19, and 04/19/19 (three incidents for this date) and the physician was not notified as ordered for these occurrences. During an interview on 05/01/19 at 8:20 AM, it was verified by the Administrator #7 and Director of Nursing #6 that the facility had no documentation to verify the physician had been notified of the blood sugar readings as ordered. Administrator #7 stated, It's not documented, I have no way of knowing if it was done or not. Director of Nursing #6, They (nursing staff) should have documented talking to the physician in the progress notes in the computer, but it's not there. At 10:05 AM on 05/01/19, Administrator #7 stated We (the facility) don't have a policy for notifying the physician of abnormal blood sugar readings, the only policy we have is on how to administer insulin.",2020-09-01
776,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2019-05-01,689,E,0,1,7QRC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and policy review, the facility failed to ensure that resident areas were free of accident hazards. Razors, cleaning products, and topical creams were found in a resident's bathroom, a soiled utility room was found to be unlocked, a cleaning product was left unattended in the shower room, body care items were left in dining room drawers, and extra medical equipment was stored in a resident's room. These observations were found during random opportunities for discovery and affected more than an isolated number of residents. Resident identifier: #28. Facility census: 96. Findings included: a) Resident #28 On 04/30/19 at 11:12 AM, Resident #28's bathroom was observed to contain numerous accident hazards. A Hot Wheels car in a box was found to be tacked over the call light pull cord, making the cord inaccessible. A box of tacks was sitting on top of a table next to the sink. Behind the sink faucet, a razor that appeared to have been used was found along with three (3) extra razor blades. To the right of the sink, three (3) more razors were found along with a screwdriver, a tube of [MEDICATION NAME] cream, and a tube of Vitamin A and D ointment. Upon further investigation, a can of Zep30 cleaner was found outside the bathroom door along with a bottle of Total Body Cleanser. Both the can and the bottle had a warning to keep the products out of reach of children. In the shower area, a bottle of Personal Cleanser was found. The bottle had a warning to keep the product out of reach of children. During an interview on 04/30/19 at 11:16 AM, the facility's Director of Nursing (DoN) confirmed that the items mentioned above were accident hazards and should not have been left in the resident's bathroom and surrounding areas. The facility's Administrator was informed of the above information on 04/30/19 at 11:23 AM. No further information was provided prior to the end of the survey. b) 200 Hallway 1. An observation on 04/29/19 at 12 PM, of the 200 hallway shower room, revealed a bottle of Pro Clean on the back of the toilet. The bottle had a warning label indicating the substance was an irritant and may be harmful if swallowed. An interview on 04/29/19 at 12:05 PM, with NA#41 verified the bottle of Pro Clean was present in the shower room used by residents and should not have been left there. 2. An observation on 04/29/19, at 02:09 PM, revealed the door to the dirty utility room was not locked and accessible to residents. Observations made inside the unlocked room included 2 sharps containers marked razors, dirty linen hampers and an unmarked container. An interview, on 04/29/19, at 02:09 PM, with NA#41 and NA#2, verified the door was unlocked and the door should be locked. An interview, on 04/30/19, at 08:18 AM, with the Maintenance Supervisor, verified the door to the soiled utility room was broken and would not always lock. Review of the policy and procedure, Infectious Medical Waste Management, CRP-SAF-IMW-005D, effective 1/93, noted The containers of infectious medical waste are kept in locked soiled utility rooms. c) 400 Hall Dining Room An observation of the 400 Hall Dining Room, on 04/30/19 at 9:20 AM, revealed the room had unlocked cabinets and drawers. The room was accessible to any resident on the 400 Hall. The cabinets and drawers contained the following items: --Two (2) containers of [MEDICATION NAME] Body Wash and Shampoo with the warning For external use only-may cause eye irritation. --One (1) container of Care Line Deodorant with the warning Keep out of reach of children-If swallowed get medical help immediately or contact a Poison Control Center. An interview with the Administrator, on 04/30/19 at 9:25 AM, revealed she had no idea why the products were in the dining room. The Administrator stated she would throw the items away immediately. d) Life Skills Room An observation of the Life Skills Room, on 04/30/19 at 11:50 AM, revealed it was being used for Resident #69's stay. The Life Skills area consists of two adjoining rooms. The first room, in which the Resident has to pass through to get to their bed and bathroom, was observed to have approximately ten (10) wheelchairs, an oxygen tank, a mechanical lift, and a weight scale stored in the room. There was just enough space for the Resident to get by the equipment to get in and out of their room. An interview with the Administrator, on 04/30/19 at 12:05 PM, revealed the Life Skills area was used as extra storage for the facility's equipment. The Administrator agreed the equipment was a concern and a hazardous environment for the Resident. The Administrator stated she would have the equipment emptied out of the room immediately.",2020-09-01
777,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2019-05-01,725,E,0,1,7QRC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility record review, medical record review and staff interview, the facility failed to assure there is sufficient qualified staff to provide nursing and related services to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Planned bi-weekly showers were not completed when two (2) Nursing Aides (NA) were scheduled to care for 29 residents. This practice has the potential to affect more than a limited number of residents. Facility census: 96. Findings included: a) Assignment sheet Review of the facility assignment sheet dated 04/29/19 revealed there were two (2) Nurse Aides and no shower or restorative aide to care for the 29 residents residing on the 100 hall. During an interview on 04/29/19 at 12:40 PM, Nurse Aide (NA) #70 confirmed there were only 2 NAs working on the 100 hall and caring for 29 residents. NA #70 reported she usually does the showers for the residents on the 100 hall on Mondays and Thursdays, but when staff call off or staffing is short she is scheduled to work the hall instead. When asked if the residents get their scheduled showers on these days. NA #70 stated: We do our best, most of the residents get washed off and don't get their scheduled shower. b) Resident (R) #78 Review of the medical record on 04/30/19, revealed R #78 suffers from [MEDICAL CONDITION] and requires assistance with activities of daily living including showers. The computerized facility task documentation form notes R #78 is scheduled to be showered every Monday and Thursday. The form dated (MONTH) 2019, indicates R #78's last shower was completed on 04/08/19. On 04/30/19 at 3:00 PM, the Director of Nursing (DON) reviewed R #78's facility task form documentation and confirmed the record lacks any documentation indicating R #78 was offered and/or showered since 04/08/19. The DON did not comment when told there was insufficient staffing on day shift to meet the needs of the residents residing on the 100 hall. Confidential staff interviews (CSI): CSI #A, reported the shower aide gets pulled to fill in when ever the facility is short staffed. The nurse aides are suppose to pick up and do the showers. When asked if the residents ever go without showers due to being short staffed, NA #A stated, If you want to know the truth, yes they do. CSI #B stated We are told to do as we can with cares, and acknowledged not everyone gets showered when staffing is short. CSI #C reported some residents' care tasks like lift transfers, showers and bed baths take more time. NA #C reviewed the 29 residents residing on the 100 hall and noted six (6) of these residents require two (2) staff members to transfer using a mechanical lift, nine (9) of the residents require one (1) to two (2) staff members to transfer, and two (2) of the residents always need two (2) staff when transferring. When asked about getting showers done when there is only two (2) nurse aides and no shower aide, NA #C stated We do the best we can and shower as many as we can. CSI #C added night shift staff can be mandated to stay over until they work a total of 16 hours and then they just leave and there is no one to replace them.",2020-09-01
778,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2019-05-01,761,E,0,1,7QRC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff 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. Two medications in the main Medication Storage Room were not labeled and dated when opened. This practice could affect more than a limited number of residents. Facility census: 96. Findings included: a) Observation An observation of the facility's main Medication Storage Room, on 05/01/19 at 7:38 AM, revealed one (1) container of [MEDICATION NAME] 23 was uncapped, unlabeled, and undated, in the refrigerator. A box of Pink [MEDICATION NAME] Anti-Diarrhea medication was also open on a shelf and not dated or labeled. b) Interview An interview with Registered Nurse (RN) #36, on 05/01/19 at 7:39 AM, revealed the medications should have been either discarded or labeled and dated once opened.",2020-09-01
779,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2019-05-01,802,E,0,1,7QRC11,"Based on observation, staff interview and resident interview the facility failed to deploy sufficient numbers of staff to assist residents and serve meals in a timely manner. This practice has the potential to affect more than a limited number of residents. Facility census: 96. Findings included: a) On 04/29/19, an observation of the noon meal service on the 100 hall found two (2) Nurse Aides (NA) passing trays to multiple residents dining in their rooms. The last tray was removed from the unheated cart by NA #70, thirty-eight (38) minutes after the cart arrived on the unit. The food on this tray was found to be at unsafe serving temperatures. NA #70 was interviewed while caring the tray to the kitchen. She reported two (2) Nurse Aides for 29 residents on the 100 hall is a normal occurrence. We are told to do our best, in regards to resident care. Resident (R) #71 was observed sitting at the end of the hall during the lunch tray pass on 04/29/19. R #71 reported the untimely meal service is a frequent occurrence on the 100 hall and acknowledged her meals are often cold when she receives them.",2020-09-01
780,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2019-05-01,804,E,0,1,7QRC11,"Based on observation, staff interview and resident interview the facility failed to serve foods at safe and appetizing temperatures. A prolonged lunch distribution resulted in unsafe food temperatures at the point of service. This practice has the potential to affect more than a limited number of residents. Facility census: 96. Findings include: a) On 04/29/19, the unheated meal cart arrived on the 100 hall at 12:20 PM. The last tray was removed by Nurse Aide (NA) #70 at 12:58 PM and immediately carried to the kitchen. Food temperatures checked by the Food Service Supervisor/cook #42 revealed the following temperatures in Fahrenheit: pureed meat and vegetables 90 degrees, cooked apples 52 degrees, juice 50 degrees and milk 49 degrees. The Food Service Supervisor acknowledged the foods were at improper temperatures and a new tray was prepared. Resident (R) #71 was observed sitting at the end of the hall during the lunch tray pass on 04/29/19. R #71 reported the untimely meal service is a frequent occurrence on the 100 hall and acknowledged her meals are often cold when she receives them. When asked if she sends the tray back or asks for the food to be warmed, R #71 stated I just don't eat it.",2020-09-01
781,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2019-05-01,805,E,0,1,7QRC11,"Based on observation and staff interview, the facility failed to provide residents with pureed food of the correct texture. This deficient practice was found during a random opportunity for discovery and affected more than an isolated number of residents. Facility census: 96. Findings included: a) Pureed Foods During an observation of the lunch meal in the dining room on 04/29/19 at 12:01 PM, several residents were observed eating pureed food that was running together on their plates. On 04/29/19 at 12:13 PM, Food Service Supervisor (FSS) #92 was interviewed about this observation. FSS #92 acknowledged that the pureed food served to several residents for lunch that day was not the correct texture. She added that the person who had prepared the pureed foods that day had made them too thin, but that she (FSS #92) did not check the pureed food to ensure it was the correct texture before allowing it to be served to residents. On 04/29/19 at 1:18 PM, the facility's Administrator was informed of the above information. No further information was provided prior to the end of the survey.",2020-09-01
782,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2019-05-01,812,E,0,1,7QRC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety. The 400 Hall Dining Room, Life Skills Room, and Kitchen, contained opened, expired, unlabeled, and undated resident food items. The Kitchen also contained a dented can, a temperature log was incomplete in a nourishment room, and the staff was touching silverware during the meal service. These practices had the potential to affect more than a limited number of residents. Facility census: 96. Findings included: a) 400 Hall Dining Room An observation of the 400 Hall Dining Room, on [DATE] at 9:20 AM, revealed the room had unlocked cabinets and drawers. The room was accessible to any resident on the 400 Hall. The cabinets and drawers contained the following items: --Five (5) containers of Captain D's Cocktail Sauce-No date/not labeled --Ten (10) containers of Captain D's Tartar Sauce-No date/not labeled --Twenty (20) packs of saltine crackers-No date/not labeled --One (1) Ziploc-plastic bag with unidentified white powder(dated [DATE]) --One (1) container of Simply Food Thickener dated ,[DATE] An interview with the Administrator, on [DATE] at 9:25 AM, revealed the staff brought most of the food items in and put them in the drawers. The Administrator stated she would throw the items away immediately. b) Life Skills Room An observation of the Life Skills Room, on [DATE] at 12:00 PM, revealed the room had several unlocked cabinets and a unlocked refrigerator. This room was accessible to anyone on the 400 Hall. The drawers and refrigerator contained the following items: --One (1) plastic container full of an unidentified white powdery substance-unmarked-undated. --Three (3) cans of sprinkles-opened/unmarked/undated. --Two (2) Kool-Aide packets-unmarked/undated. --One (1) container of Strawberry Jelly-unmarked/undated. --One (1) cup of ice cream-unmarked/undated. --One (1) package wrapped in foil labeled chicken breast with a date of ,[DATE]. --One (1) sandwich in a plastic bag-unmarked/undated. An interview with the Administrator, [DATE] at 12:07 PM, revealed the food items should have never been left in the room. The Administrator stated she would throw the items away immediately. c) Main Kitchen An initial tour of the facility's main kitchen began on [DATE] at 11:00 AM. At 11:04 AM on a shelf in the dry storage area, a six (6) pound nine (9) ounce can of whole potatoes was found to have a large dent near the top seam of the can. The dent had been circled with a black marker, suggesting that someone had noticed the dent before placing the can on the shelf with other non-dented cans to be used for preparing resident meals. Food Service Supervisor (FSS) #92 stated at the time of the finding that the dented can should not have been on the shelf where it was found. FSS #92 said that dented cans go in a separate area of the dry storage room, away from the cans used for meal service. At 11:06 AM, a small piece of cheesecake was found in an unlabeled container in a reach-in refrigerator in the kitchen. FSS #92 acknowledged that the cheesecake should have been labeled and dated. FSS #92 removed the item from the refrigerator at the time of the finding. During the survey, a review of the facility's food safety policy found that the nursing facility will store food in accordance (sic) professional standards for food service safety. The facility's Administrator was notified of the above information on [DATE] at 1:18 PM. No further information was provided prior to the end of the survey. d) Dining Room During an observation of the lunch meal in the dining room on [DATE] at 11:50 AM, Nursing Assistant (NA) #2 was observed touching with her bare hands the parts of a resident's silverware that would touch both the resident's food and mouth. During an interview at 11:51 AM, NA #2 said that silverware was not to be touched with bare hands on the part that would touch a resident's food and mouth. On [DATE] at 1:18 PM, the facility's Administrator was notified of the above findings. No further information was provided prior to the end of the survey e) Nourishment Room On [DATE] at 2:20 PM, the temperature log on the refrigerator in the nourishment room on the 300-hall was found to have a blank spot on [DATE], suggesting that the temperature of the refrigerator had not been taken on that date. At the time of the finding, FSS #92 agreed that the temperature log was not filled out correctly. The above finding was discussed with the facility's Administrator on [DATE] at 3:05 PM. No further information was provided prior to the end of the survey.",2020-09-01
783,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2019-05-01,814,D,0,1,7QRC11,"Based on observation and staff interview, the facility failed to ensure that refuse was disposed of properly. This deficient practice was found during a random opportunity for discovery and had the potential to affect an isolated number of residents. Facility census: 96. Findings included: On 04/30/19 at 8:59 AM, three (3) dumpsters were observed behind the facility. No staff was present near the dumpsters. Two (2) of the dumpsters had been left open, creating the potential for the entrance of pests into the dumpster. Housekeeping Attendant (HA) #63 entered the dumpster area at 9:02 AM. Upon leaving the area, HA #63 acknowledged that two (2) of the three (3) dumpsters had been open when she approached the area. She said that she closed one (1) of the dumpsters, but that the other dumpster was typically left open because it had a large lid. She added that all three (3) dumpsters were supposed to remain closed. On 04/30/19 at 9:30 AM, the facility's Administrator was made aware of the above findings and agreed that all three (3) dumpsters should have been closed. No further information was provided prior to the end of the survey.",2020-09-01
784,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2019-05-01,842,D,0,1,7QRC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain a complete and accurate medical record for each resident. Resident #23's medical record lacks information related to scheduled psychiatric visits. This was true for one (1) of five (5) residents reviewed for necessary medications. Resident identifier: #23. Facility census: 96. Findings included: a) Review of the medical record on 05/01/19 revealed resident #23's [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 02/05/19, notes R#23 experienced delusions and rejected care one (1) to three (3) days of the seven (7) day look back period. Medications include an antipsychotic, antidepressants and a hypnotic. The computerized physician orders [REDACTED]. The monthly pharmacy consultation reports note the following physician documentation: --04/22/19 - a gradual dose reduction (GDR) for [MEDICATION NAME] 20 milligrams (mg) daily was declined and states (typed as written): refer to her psychiatrist. --03/15/19 - a GDR for [MEDICATION NAME] 15 mg at bedtime and a recommendation to decrease multiple antidepressants were declined and states (typed as written): refer to her psychiatrist. The medical record lacks any psychiatric evaluations since 05/31/18. *No other psychiatric assessment and plans of care are located in the medical record. During an interview on 05/01/19 at 9:00 AM, the Director of Nursing (DON) acknowledged R#23 visits a psychiatrist regularly. The DON reviewed the chart and confirmed there are no records related to R#23's psychiatric evaluations since 05/31/18.",2020-09-01
785,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2019-05-01,868,E,0,1,7QRC11,"Based on the review of Quality Assessment and Assurance (QAA) Meeting Attendance Records and staff interview, the facility failed to ensure the Facility's Medical Director attended quarterly (QAA) meetings. The Medical Director failed to attend two of the last three QAA meetings held at the facility. This practice had the potential to affect more than a limited number of residents. Facility census: 96. Findings included: a) Quality Assessment and Assurance (QAA) Meeting Attendance Records review A review of the attendance records for the last three QAA meetings was conducted on 05/01/19. The facility conducted quarterly QAA meetings in (MONTH) (YEAR), (MONTH) 2019, and (MONTH) 2019. The Attendance Records for these meetings revealed the Medical Director was absent for the (MONTH) (YEAR) and (MONTH) 2019 meetings. b) Interview An interview with the Administrator, on 05/01/19 at 10:30 AM, revealed the Medical Director is required to attend the quarterly QAA meetings. The Administrator confirmed the Medical Director did not attend the (MONTH) (YEAR) or (MONTH) 2019 QAA meetings.",2020-09-01
786,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2019-05-01,880,E,0,1,7QRC11,"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. A nurse failed to wash her hands during medication administration and a resident's bathroom was being used to store multiple items therefore impeding the proper cleaning and sanitation of the room. These practices affected more than a limited number of residents. Resident identifiers: #23, #46, #70 and #28. Facility census: 96. Findings include: a) Medication Administration An observation during medication administration, on 05/01/19 at 7:30 AM, revealed Registered Nurse (RN) #36 failed to wash her hands between administering medications to Resident #23, #46, and #70. An interview with RN #36, on 05/01/19 at 7:50 AM, revealed she got nervous and forgot to wash her hands. The RN stated she is always supposed to wash her hands before and after each resident during medication administration. b) Hot Wheels Cars During an observation of Resident #28's bathroom on 04/30/19 at 11:12 AM, the walls of the main part of the room were found to be lined with Hot Wheels cars. The cars, in boxes, were tacked to the walls, covering them almost entirely from floor to ceiling. A small area of wall above the cars contained rows of tacks which appeared to have been able to accommodate more cars. Additionally, a set of plastic drawers that appeared to be filled with more cars was touching the floor near the toilet. Beside the toilet was a urinal touching the floor and an opened container of potato chips on a table. A typed sign beside the toilet warned the bathroom's visitors not to rearrange any of the items in the room. Upon further examination, the bathroom had a second part to it that could be accessed through an open archway. In that portion of the bathroom, there was a shower to the left and a shelving unit to the right. The inside of the shower was piled high with cardboard boxes and the shelving unit was piled with visibly soiled plastic boxes containing more cars. At 11:16 AM, the facility's Director of Nursing (DoN) entered the bathroom and asked if everything was alright. The DoN was asked how Resident #28's bathroom could be cleaned thoroughly when the walls were covered with cars and the floors, shelves, and shower contained numerous boxes and other types of storage containers filled with cars. The DoN acknowledged that the collection of cars in the bathroom posed an infection risk, as the bathroom could not be cleaned thoroughly. At 11:23 AM, the facility's Administrator was notified of the above findings. She agreed that the cars in the bathroom posed an infection risk. No further information was provided prior to the end of the survey.",2020-09-01
789,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2017-07-19,156,D,0,1,HITB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to notify the beneficiary/responsible party of the facility's decision to terminate Medicare services for two (2) of three (3) residents reviewed for the care area of liability notices and beneficiary appeal. This failed practice had the potential to affect an isolated number of residents. Resident identifiers: #8 and #13. Facility census: 100. Findings include: a) Staff Interview At 2:15 p.m. on 07/17/17, the facility social worker, (SW) #102, was asked to provide copies of the information given to the three (3) residents selected by the Quality Indicator Survey (QIS) for review of the care area: Liability Notices and Beneficiary Appeal. The QIS automatically selects three (3) residents discharged from Medicare services within the last six (6) months to determine if the appropriate denial notice was provided. The SW #102 said he was unable to find any information for two (2) Residents: #8 and #13. The facility's resident financial coordinator, (RFC) #30 said she did not have copies of any notices given to Residents #8 and #13 at 2:20 p.m. on 07/17/17. b) Resident #8 At 2:20 p.m. on 07/17/17, RFC #30 verified Resident #8 was re-admitted to the facility on [DATE] and was covered by Medicare, Part A services. The resident was discharged from Medicare services on 06/13/17 and remained at the facility. c) Resident #13 At 2:20 p.m. on 07/17/17, RFC #30 verified Resident #13 was re-admitted to the facility on [DATE]. The resident was covered by Medicare, Part A services. Resident #13 was discharged from Medicare services on 03/09/17. The resident left the faciity on [DATE]. At 2:31 p.m. on 07/17/17, the administrator said he checked with the therapy department and he was unable to find the notices given to Resident's #8 and #13 for denial of Medicare covered services.",2020-09-01
790,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2017-07-19,160,E,0,1,HITB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the resident trust funds and staff interview, the facility failed to convey the balance of funds of a deceased resident to the individual or probate jurisdiction administering the resident's estate, in accordance with State law. This was true for three (3) of ten (10) residents who expired at the facility within the last ninety (90) days. Resident identifiers: #50, #20, and #34. Facility census: 100. Findings include: a) Resident #50 At 2:28 p.m. on [DATE], the facility's Resident Financial Coordinator (RFC) #30 provided information Resident #50 expired on [DATE]. A check made payable to the resident's responsible party on [DATE] for the amount of $54.92, the balance of the resident's personal trust account. b) Resident #20 At 10:01 a.m. on [DATE], RFC #30 verified resident #20 expired at the facility on [DATE]. On [DATE] a check was made payable to the Resident's son for the sum of $350.20, the balance of the resident's personal trust account. c) Resident #34 At 10:01 a.m. on [DATE], RFC #30 verified resident #35 expired at the facility on [DATE]. A check was made payable to the resident's responsible party on [DATE] for the sum of $1,758.33, the balance of the resident's personal trust account. Once a resident has expired, the balance of funds remaining at the facility must go to the individual or probate jurisdiction administering the resident's estate. RFC #30 verified she had no evidence the above parties, to whom the balance of the resident's funds were given, had qualified to settle the resident's estates at 10:01 on [DATE]. At 10:30 a.m. on [DATE], RFC #30 said she knew the checks should have been made to the resident's estate but she just forgot. She said this is normally what she does.",2020-09-01
793,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2017-07-19,272,D,0,1,HITB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident review and record review, the facility failed to ensure comprehensive Minimum Data Set (MDS) assessments were accurate and complete for five (5) of 22 resident's whose MDS assessments were reviewed during Stage 2 of the Quality Indicator Survey (QIS). MDS assessments for Resident's #53, #38, and #119 were inaccurate in the care area of oral/dental status. MDS assessments for Resident #15 was inaccurate in the care area of ulcers, wounds and skin problems. MDS assessments for Resident #47 was inaccurate in the care area of diagnosis. Resident identifiers: #38, #53, #119, #15, and #47. Facility census: 100. Findings include: a) Resident #38 Observation of the resident during Stage 1 of the Quality Indicator Survey (QIS) at 4:04 p.m. on 07/10/17, found the resident had no natural teeth. The resident said she did not have and did not want any dentures. Review of the resident's admission MDS, with an assessment reference date (ARD) of 05/01/17 at 2:00 p.m. on 07/11/17, found section (L), entitled oral/dental status, did not code the resident as having no natural teeth. During an interview with the resident's unit manager, Registered Nurse (RN), at 2:59 p.m. on 07/11/2017, she verified the resident did not have any natural teeth. She said she thought the resident had dentures but her sister took them home with her. The resident's sister was interviewed at 3:59 p.m. on 07/10/17, during Stage 1 of the Quality Indicator Survey (QIS) as a family interview. The sister had previously verified the resident did not have any dentures and did not want any during the telephone interview. Registered Nurse (RN) #27, the MDS Coordinator, said she did not know if the resident had any natural teeth or not. She was asked to observe the resident's oral cavity at 3:16 p.m. on 07/11/17. After observation, RN #27 confirmed Resident #53 had no natural teeth and she further confirmed the MDS should have been coded, no natural teeth or tooth fragments (edentulous). At 3:45 p.m. on 07/11/17, the Director of Nursing (DON) was advised of the above deficient practice. She had no further information to provide. b) Resident #53 An interview with the Resident during Stage 1 of the QIS, at 07/10/17 at 12:30 p.m., revealed the resident had an upper denture and no natural teeth. She said she lost her bottom denture before coming to the nursing home. Review of the admission admission MDS with an ARD of 10/21/17, found the facility did not code the resident's dental status correctly. At 11:19 a.m. on 07/17/17, RN #27 confirmed the admission MDS was not coded correctly. She stated she should have checked box B-noting the resident had no natural teeth or tooth fragments (edentulous). c) Resident #119 During Stage 1 of the Quality Indicator Survey (QIS), on 07/10/17 at 04:01 p.m., observations and interview with Resident #119 revealed he had no natural teeth, and he said he had been edentulous for years. On 07/17/17 at 2:51 p.m., interview with Registered Nurse (RN) and review of the admission nursing evaluation, dated 03/13/15, revealed Resident #119 has denture but the wife said kept the dentures at home because the resident did not like to wear them. Review of records, on 07/18/17 9:26 a.m., of the annual Minimum Data Set (MDS) with an Assessment Reference Date of 12/27/16, revealed the dental status section is marked No as a response to no natural teeth when it should have been marked Yes to reflect, the resident had no natural teeth. On 07/18/17 at 9:18 a.m., an interview with Nurse Aide (NA #29) revealed NA #29 provided oral care for resident since he was admitted . The NA stated the resident had no natural teeth and does not wear dentures, and had no dentures in his room. The NA stated the resident told her his wife had his dentures at home. Interview with the MDS Coordinator RN #27, on 07/18/17 at 10:14 a.m., revealed the MDS Nurse agreed the annual MDS with an ARD 12/27/16, Section L0200b was marked incorrectly, and should have been marked Yes instead of No, indicating, yes, the resident had no natural teeth. d) Resident #15 Observations of Resident #15, on 07/11/17 at 09:32 a.m., revealed the resident had a raw red open area the size of a pea on the bridge of her nose and a smaller scabbed area on the side of her face near her right eye. Interview and review of records with RN #80, on 07/12/17 at 2:59 p.m., revealed RN #80 was not aware of any open or scabbed area on the resident's nose or face, and review of record did not show any treatment was ordered. RN #80 went with surveyor to observe the resident. RN #80 agreed there were open and scabbed areas on the resident's nose and face, and she would let the wound treatment nurse assess. Review of the admission photo taken on 03/10/17 showed the areas were present on admission. On 07/12/17 at 3:13 p.m., review of admission nursing assessment, dated 03/10/17, did not indicate any issues with skin on the resident's nose or face, even though areas are plainly seen on the resident's admission photo. Review of skin assessments dated 03/14/17 and 3/27/17, reviewed on 07/12/17 at 3:17 p.m., identified the area on the resident's nose. On 07/12/17 at 5:22 p.m., review of admission MDS dated [DATE] revealed resident's brief Interview for mental status (BIMS) score was three (3) indicating resident has a severe cognitive impairment. Under section noting skin condition (M1040d.) Open [MEDICAL CONDITION] other than ulcers, rashes, cuts was marked no and should have been marked yes. Interview with RN #44, on 07/19/17 at 10:55 a.m., upon review of Resident #15's admission photo with RN #44, revealed RN #44 agreed the skin area was present at admission and should have been indicated on the admission nursing assessment and admission MDS. e) Resident #47 During a record review, on 07/17/17 at 10:44 a.m., it was discovered the Minimum Data Set (MDS) comprehensive assessment with an assessment reference date (ARD) of 03/26/17, did not include [MEDICAL CONDITION] as a [DIAGNOSES REDACTED]. A review of the current physician's orders [REDACTED]. In an interview with the MDS Coordinator, on 07/17/2017 at 11:54 a.m., verified the comprehensive (MDS) assessment for Resident #47, completed on 03/26/17 did not include the [DIAGNOSES REDACTED].",2020-09-01
796,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2017-07-19,280,D,0,1,HITB11,"Based on record review and staff interview, the facility failed to revise the care plans of two (2) of twenty-two (22) care plans reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident #123's care plan was not updated to reflect a decline in activities of daily living (ADL's). Resident #86's care plan was not updated in the care area of accidents. Resident identifiers: #123 and #86. Facility census: 100. Findings include: a) Resident #123 A decline in the residents ADL's was reflected on her last minimum data set (MDS), a quarterly with an assessment reference date (ARD) of 06/20/17 when compared to the previous quarterly MDS with an ARD of 03/20/17. On the 03/20/17 MDS, locomotion on unit: self-performance, was coded as requiring supervision. The most recent MDS, with an ARD of 06/20/17 coded locomotion on the unit as requiring limited assistance. Locomotion off unit: was coded as self-performance, on the 03/20/17 MDS. On the 06/20/17 MDS the activity declined to activity occurred only once or twice - activity did occur but only once or twice. Dressing declined from requiring Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance to Extensive assistance - resident involved in activity, staff provide weight-bearing support. Toilet use declined form requiring Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance to Extensive assistance - resident involved in activity, staff provide weight-bearing support. Review of the resident's current care plan found the problem: --The resident has an ADL self-care performance deficit related to impaired mobility and cognition, dementia, dated 06/10/16. The goal related to this problem was: --The resident will improve current level of function in (bed mobility, transfers, eating, dressing, toilet use and personal hygiene, ADL score through the next review, revised on 04/28/16. At 11:19 a.m. on 07/19/17, the administrator confirmed the care plan was not updated to reflect the current decline in ADL's. b) Resident #86 Review of care plan, on 07/11/17 at 1:30 p.m., revealed a focus Risk of injury related to smoking with the intervention, observe during smoking breaks and alert nursing to any concerns as needed. The facility is a smoke free facility and does not allow smoking on the premises. The care plan needed to be revised to reflect the no smoking policy. The resident was reviewed for accidents hazards as the resident was observed smoking without supervision. Investigation revealed the resident had capacity, had been assessed to be a safe smoker and was allowed to smoke off the facility property. c) Resident #86 Review of care plan, on 07/11/17 at 1:30 p.m., revealed a focus 'Risk of injury related to smoking' with the intervention observe during smoking breaks and alert nursing to any concerns as needed. The facility is a smoke free facility and does not allow smoking on the premises. The care plan needed to be revised to reflect the no smoking policy. The resident was reviewed for accidents hazards as the resident was observed smoking without supervision. Investigation revealed the resident had capacity, had been assessed to be a safe smoker and was allowed to smoke off the facility property.",2020-09-01
797,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2017-07-19,282,E,0,1,HITB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to implement care plans for five (5) of twenty-two (22) care plans reviewed in the areas of accidents and unnecessary medications. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #119, #123, #55, and #30. Facility census: 100. Findings include: a) Resident #119 An interview with Resident #119, on 07/18/17 at 2:25 p.m., revealed the resident had severely impaired vision, and was to wear a yellow wrist band bracelet on his wrist indicating he was a fall risk. The resident was observed multiple times during the annual Quality Indicator Survey (QIS), 07/10/17 through 07/20/17, and never once was seen wearing a yellow wrist band bracelet. When asked if he wore a yellow wrist band bracelet on his wrist, the resident felt both wrist, and said, Yes, I use to have one on. I don't know what happened to it. Registered Nurse (RN #44) reviewed the care plan with this surveyor, on 07/18/17at 2:29 p.m., and agreed Resident #119 according to his care plan was to have a yellow wrist band bracelet on to indicate he was a fall risk. This surveyor requested RN #44 come to the resident's room to observe the resident. Resident #119 was laying on his bed, and RN #44 looked at both wrists and asked the resident where his wrist band bracelet was. The resident said he didn't know and did not know how long he had been without the wrist band bracelet. RN #44 placed a yellow wrist band bracelet on the resident's wrist after surveyor intervention. b) Resident #123 Record review on 07/12/17, at 8:10 a.m., revealed the resident had three (3) falls in the last six (6) months. On 02/17/17, the resident was observed seated on the side of the bed. Three (3) minutes later the resident was observed sitting in the floor after taking right shoe off to replace with a slipper. The resident slid off the bed while trying to fit slipper onto right foot. The resident had no injuries. On 05/23/17, the resident was found on the floor on her stomach with arms in front of her and legs behind. The residents head is up and looking forward at end of bed at foot board facing the door. A small scratch was noted to the right hand. Resident had shoes on and walker within reach to the left of the resident. She had a small scratch to the right hand. The resident fell again on 07/10/17. The resident was found on the floor beside her bed. The resident was wearing shoes and had her left shoe lace untied. She had bruising to her left hand. A fall risk screen, completed on 07/09/17, noted the fall risk preventions in place: --Nonskid footwear, --Bed in lowest position, --Call light within reach, --Offer toileting, and --Fluids and snacks. Review of the resident's care plan found the following problem: --Resident is at risk for falls related to malaise, impaired mobility, cognition, and ataxic gait. The goal associated with the problem was: --The resident will be free of falls through the review date. Approaches included: --Perimeter border to bed. Review of the physician's orders [REDACTED]. Observation of the resident at 9:22 a.m. on 07/12/17, found she was in bed sleeping. Her bed was not in a low position. No perimeter border was on the bed. A second observation at 10:21 a.m. on 07/12/17, found she was still sleeping and bed was not in lowest position. No perimeter border was on the bed At 10:45 a.m., plant operations manager #22, was in the hallway just outside the resident's room. He was asked if the residents bed was in the lowest position. He stated the bed was electric and he believed the bed could be lower to the floor. At 10:46 a.m., the Registered Nurse (RN), unit manager #53, was asked to observe the resident in her bed. RN #53 verified the bed was not in the lowest position and verified the bed did not have a perimeter border mattress as ordered by the physician. On 07/17/17 at 1:40 p.m., the director of nursing (DON) was advised of the above situation. She confirmed her staff had told about the situation and a perimeter border was added to the resident's bed. She resident's care plan was reviewed with the DON who confirmed the care plan had not been implemented as directed. c) Resident #55 A review of Resident #55's medical record at 2:19 p.m on 07/18/17 found the following physician orders: -- Eliquis 5 milligrams (mg) by mouth beginning on 05/21/17. -- Aspirin 81 mg by mouth beginning on 05/21/17. A review of Resident #55's care plan found the following focus statement: --The resident is on Anticoagulation Therapy r/t (related to) [MEDICAL CONDITION]. This focus statement had a created date of 05/12/17. The goal associated with this focus statement read: --The resident will be free from discomfort or adverse reactions related to anticoagulant use the review date by no bruising or bleeding. The target date for this goal was 08/23/17. Interventions related to this focus statement and goal included: --Review medication list for adverse interactions. Avoid use of aspirin and NSAIDS. A review of the Medication Administration Record [REDACTED]. An interview with the Director of nursing (DON) at 9:14 a.m. on 07/19/17 confirmed Resident #55 received Eliquis and Aspirin daily since 05/21/17 and agreed the care plan for Resident #55 had not been implemented. d) Resident #30 The care plan was not followed for avoiding the use of aspirin with the administration of anticoagulants. A review of the current care plan showed interventions instructing staff to avoid the of use of aspirin with anticoagulant medication due to adverse reactions but a review of the Medication Administration Record [REDACTED]. There were orders for- Aspirin 81 mg, 1 tab by mouth two (2) times a day for [MEDICAL CONDITION] related to chronic embolism of deep veins with a start date of 01/13/17. Additional orders were for: Eliquis for [MEDICAL CONDITION] 5 mg, 1 tab by mouth 1 tab two (2) times a day for history of blood clot in leg related to chronic embollism and [MEDICAL CONDITION] of deep vein of left lower extremity with a start date of 04/28/17. This resulted in the staff not implementing the care plan interventions as required.",2020-09-01
801,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2017-07-19,428,E,0,1,HITB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility's consultant pharmacist failed to identify a clinically significant medication interaction between Aspirin and Eliquis for Residents #161, #14, #30, #55. For Resident #123, the consultant pharmacist failed to identify the antihypertension medication (Clonidine) was not being administered as prescribed. Resident identifiers: #161, #14, #30, #55, and #123. Facility census: 100. Findings include: a) Resident #161 A review of Resident #161's medical record at 12:19 p.m. on 07/18/17 found the following physician orders: -- Eliquis 5 milligrams (mg) by mouth beginning on 05/24/17. -- Aspirin 81 mg by mouth beginning on 05/24/17. Review of Resident #161's comprehensive care plan initiated on 05/23/17, found no focus, goal or interventions for his use of an anticoagulant medication. A review of the Medication Administration Record [REDACTED]. Further review of the medical record found the pharmacist reviewed the residents Drug Regimen in (MONTH) (YEAR) but failed to identify the irregularity of Resident #161 receiving Aspirin while also receiving Eliquis. According to the Physician Desk Reference (PDR),concomitant use of apixaban with other agents that alter hemostasis such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), platelet aggregation inhibitors, or thrombolytic agents may increase the risk of bleeding. It is a highly clinically significant interaction and avoid combinations; the risk of the interaction outweighs the benefit. An interview with the Director of nursing (DON) at 9:14 a.m. on 07/19/17 confirmed Resident #161 received Eliquis and Aspirin daily since 05/24/17 and agreed the pharmacist failed to identify this irregularity when completing his review in (MONTH) of (YEAR). b) Resident #14 A review of Resident #14's medical record at 3:19 p.m. on 07/18/17 found the following physician orders: --Eliquis 5 milligrams (mg) by mouth beginning on 02/28/17. --Aspirin 81 mg by mouth beginning on 02/28/17. A review of the Medication Administration Record [REDACTED]. Further review of the medical record found the pharmacist reviewed the residents Drug Regimen in (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) but failed to identify the irregularity of Resident #14 receiving Aspirin while also receiving Eliquis. According to the Physician Desk Reference (PDR),concomitant use of apixaban with other agents that alter hemostasis such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), platelet aggregation inhibitors, or thrombolytic agents may increase the risk of bleeding. It is a highly clinically significant interaction and avoid combinations; the risk of the interaction outweighs the benefit. An interview with the Director of nursing (DON) at 9:14 a.m. on 07/19/17 confirmed Resident #14 received Eliquis and Aspirin daily since 02/28/17 and agreed the pharmacist failed to identify this irregularity when completing his review in (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) of (YEAR). c) Resident #123 Record review found the resident was admitted to the facility on [DATE]. Review of the current physician's orders [REDACTED]. The resident was also receiving Lisinopril 20 mg's daily, and Metoprolol Tartrate 25 mg's daily, both for a [DIAGNOSES REDACTED]. Review of the resident's blood pressures since 01/16/17 found the following occasions when the Clonidine should have been administered: --02/27/17 at 9:07 p.m. with a blood pressure of 195/75 --03/18/17 at 8:02 p.m. with a blood pressure of 190/78 --05/24/17 at 7:29 p.m. with a blood pressure of 175/103 --05/24/17 at 7:31 p.m. with a blood pressure of 170/104 --05/24/17 at 7:35 p.m. with a blood pressure of 168/106 Review of the Medication Administration Record [REDACTED]. At 1:52 p.m. on 07/17/17, the director of nursing (DON) provided copies of the resident's blood pressures and the MAR's for (MONTH) (YEAR), (MONTH) (YEAR), and May, (YEAR). The DON said she could not find any nursing documentation to indicate the medication was administered or any documentation as to why the medication was not administered as directed on 02/27/17, 03/18/17 and 05/24/17. In addition, the resident's blood pressure should have been obtained every six (6) hours per the physician's orders [REDACTED]. At 1:30 p.m. on 07/18/17, the DON verified the residents blood pressure was not taken every six (6) hours on any day since being prescribed. Since the start of the Clonidine, the pharmacist reviewed the resident's medication monthly on 01/23/17, 02/26/17, 03/26/17, 04/17/17, 05/10/17 and 06/21/17. The pharmacist found no irregularities during each visit. The pharmacist made no comment regarding the resident's drug regime of three (3) medications (duplicate therapy) - all prescribed for essential hypertension. The pharmacist did not recognize the Clonidine was not administered as directed. The DON was unable to provide any documentation the pharmacist had recognized the Clonidine was not administered as directed by the physician's orders [REDACTED]. d) Resident #55 A review of Resident #55's medical record at 2:19 p.m. on 07/18/17 found the following physician orders: --Eliquis 5 milligrams (mg) by mouth beginning on 05/21/17. --Aspirin 81 mg by mouth beginning on 05/21/17. A review of Resident #55's care plan found the following Focus Statement: --The resident is on Anticoagulation Therapy r/t (related to) atrial fibrillation. This focus statement had a created date of 05/12/17. The goal associated with this focus statement read: --The resident will be free from discomfort or adverse reactions related to anticoagulant use the review date by no bruising or bleeding. The target date for this goal was 08/23/17. Interventions related to this focus statement and goal included: --Review medication list for adverse interactions. Avoid use of aspirin and NSAIDS. A review of the Medication Administration Record [REDACTED]. Further review of the medical record found the pharmacist reviewed the residents Drug Regimen in (MONTH) (YEAR) but failed to identify the irregularity of Resident #55 receiving Aspirin while also receiving Eliquis. An interview with the Director of nursing (DON) at 9:14 a.m. on 07/19/17 confirmed Resident #55 received Eliquis and Aspirin daily since 05/21/17 and agreed the pharmacist failed to identify this irregularity when completing his review in (MONTH) of (YEAR). Resident #30 The registered pharmacist failed to recognize irregularities concerning Aspirin and Elequis interaction for resident #30. The resident had current orders for: Aspirin 81 mg, 1 tab by mouth 2 times a day for heart disease related to chronic embolism of deep veins and Eliquis for DVT (deep vein thrombosis) 5 mg, 1 tab by mouth 2 times a day for history of blood clot leg related to chronic embolism and thrombosis of deep vein of LLE (left lower extremity) with a start date 4/28/17. The current care plan indicated the resident has a problem listed as the use of anticoagulant and the interventions is to avoid the use of aspirin. Care plan was not followed re; avoiding the use of aspirin with the administration of anticoagulants. A review of the medication regimen review by the registered did not show that he had identified this as a concern and alerted the staff to the contraindications of the use of the two medicines together. The physician could have been notified and written a rationale why it would be acceptable to give these meds at the same time. Spoke with DON on 07/18/17 at 10:10 a.m. she confirmed the pharmacist had not noted any irregularity regarding the use of Eliquis and aspirin as treatment modalities at the same time.",2020-09-01
805,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2017-07-19,514,E,0,1,HITB11,"Based on observation, record review and staff interview, the facility failed to ensure the residents record was accurate and complete regarding resident's signing in and out of the facility on leave of absence. This was true for four(4)of twenty-two(22) medical records reviewed. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #86, #174, #38, and #65. Facility census: 100. Findings include: a) Resident #86 Interview with Registered Nurse (RN) #80, on 07/12/17 at 2:12 p.m., revealed residents with capacity can leave the facility property when they choose, but they must sign in and out in their books. Review of records indicate Resident #86 has capacity. When asked to see Resident #86 sign in and out sheet, RN #80 showed this surveyor Resident #86's Release of Responsibility for Leave of Absence form, which is the form used to sign in and out of the facility. The last entry date observed on the form was 07/01/17. When asked when the last time Resident #86 left the facility property, RN #80 said according to this form he signed out and left the facility property last on 07/01/17. During the annual Quality Indicator Survey (QIS), 07/10/17 through 07/20/17, Resident #86 was observed on multiple days (7/11/17, 07/12/17, 7/13/17, 07/17/17, 7/18/17, and 07/20/17) leaving the facility property. There was no evidence of the resident signing in or out of the facility or evidence the staff was monitoring when the resident was out of the facility on the days the resident was observed leaving the facility property. b) Resident #174 A review of Resident #174's medical record on 07/17/17 at 2:00 p.m. found a Release of Responsibility for Leave of Absence form. This form had a column for the date and hour the resident left the facility and also a column for the date and hour the resident returned to the facility as well as a column to document the residents condition upon return to the facility. The form also contained a column for the resident or responsible party to sign. A review of this form for the time frame of 07/11/17 through present found Resident #174 signed out on the following dates and times, but the date and time the resident returned was not completed by the Resident nor by the facility staff. The dates and times are as follows(please note a.m. and/or p.m. unless noted was not distinguished on the form at the time the resident signed out): --07/11/17 at 1:55 p.m --07- Date and time other than a 7 (seven) was blank --07/12/17 at 3:40 p.m. An interview with the Director of Nursing at 9:20 a.m. on 07/19/17 confirmed the date and time Resident #174 returned to the facility was not noted on the Release of Responsibility form. c) Resident #38 Review of the resident's medical record found a form entitled, Release of Responsibility for Leave of Absence. The form directed the following: I hereby accept full responsibility and absolve management of the Nursing Home, its personnel and attending physician of responsibility for any accident, mishap or deterioration of condition above named patient is away from _________ on the date indicated below. The form required completion of the following information: --date leaving, the hour, the signature of responsible party or patient, witness, date returned, hour returned and condition on return. On 07/03/17, the resident signed herself out of the facility on three (3) separate occasions. On the first occasion, the time was 6:25. It is unknown if this was 6:25 p.m. or 6:25 a.m. The date the resident returned, the hour the resident returned, and the condition on the return was not completed. On 07/04/17 the resident left the facility at 5:05, unknown if this is a.m. or p.m She left again on two (2) more occasions with the time unknown. The date, hour, and condition of the resident upon return was never completed. On 07/11/17, the resident signed out at 9:11 a.m The date and time of the return and her condition upon return was never completed. The resident signed out on two more occasions on this date with no other information completed, other than the resident's signature. On 07/12/17, the resident left the faciity on one (1) occasion. The time she left, the date, time, and condition upon return was not completed. d) Resident #65 A review of resident #65's medical record on 07/17/17 at 12:00 p.m. found a Release of Responsibility for Leave of Absence form. This form had a column for the date and hour the resident left the facility and also a column for the date and hour the resident returned to the facility as well as a column to document the residents condition upon return to the facility. The form also contained a column for the resident or responsible party to sign. A review of this form for the time frame of 06//27/17 through present found Resident #65 signed out on the following dates and times, but the date and time the resident returned was not completed by the Resident nor by the facility staff. The dates and times are as follows(please note a.m. and/or p.m. unless noted was not distinguished on the form at the time the resident signed out) : --06/27/17 at 10:30, at 12:30, and at 4:30. --06/28/17 at 12:30, 5:30, 8:30, and 11:30. --06/29/17 8:30. --07/04/17 3:30. --07/05/17 at 11:30. --07/06/17 at 12:30. --07/07/17 at 7:55. --07/08/17 at 11:30. --07/09/17 at 4:30. --07/10/17 at 11:30, 4:00, and 6:00. --07/11/17 at 9:15, and 1:55. --07/12/17 at 11:30, 3:10 p.m. , and 4:20. --07/13/16 at 12:20 p.m. --07/15/17 at 1:00 p.m. An interview with the Director of Nursing at 9:20 a.m. on 07/19/17 confirmed the date and time Resident #65 returned to the facility was not noted on the Release of Responsibility form. e) Emergency The failure of the facility to track when residents leave and return to the building could pose a serious problem if there was an emergency which required the evacuation of the building. The Nursing Home Administrator and the Director of Nursing in an interview at 10:58 a,m. on 07/19/17 both agreed that this could pose a problem should an emergency arise. They agreed this was a problem which needed attention.",2020-09-01
807,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2018-08-01,657,D,0,1,68SA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to update a care plan with therapy recommendations. This affected one (Resident #10) of one sampled resident reviewed for therapy. The facility census was 102. Findings included: a) Resident #10 The clinical record was reviewed on 08/01/18 at 7:12 AM. Resident #10 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. A care plan for Resident #10 entitled, resident on a passive range of motion (PROM) program was reviewed on 08/01/18 at 7:15 AM. The care plan revealed an entry dated 07/06/18 noting Resident #10 was on the PROM program for his hips knees and ankles. There was no care plan entry for Resident #10's upper extremities. On 08/01/18 at 7:36 AM, an interview was completed with Occupational Therapist (OT) #221. OT #221 stated Resident #10 was discharged from occupational therapy services on 07/09/18. At discharge, The goal was to have hand splints on an hour a day if he tolerated them. Restorative (nursing aide) was to put the splints on the resident and take them off. On 08/01/18 at 9:42 AM, an interview was completed the Director of Nurses (DON). The DON said following completion of therapy, a resident may be referred to the restorative nursing program. Currently, either the DON or Nurse #18 would review the Therapy to Restorative Evaluation form. She would update the care plan with the new orders. The DON stated on 07/09(18), OT #221 did a Therapy to Restorative Evaluation form that said (Resident #10) should get range of motion to the upper extremities with hand splints. I don't see the order was written and no task was done. It wasn't put on restorative's list of things to complete. We would update the care plan when we write the order. He doesn't have an order, a task and no care plan for the hand splints. .",2020-09-01
808,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2018-08-01,688,D,0,1,68SA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interviews, the facility failed to provide appropriate treatment to maintain range of motion of a resident's hands. This affected one (Resident #10) of one sampled resident reviewed for range of motion. The facility census was 102. Finding include: a) Review of the medical record on 08/01/18 at 7:12 AM revealed Resident #10 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] was reviewed on 08/01/18 at 7:13 AM and noted that Resident #10 had upper extremity limitations on both sides. Resident #10 was also noted to have both short and long-term memory problems and severely impaired decision-making. Resident #10 was totally dependent upon one to two staff members for all activities of daily living. The care plan entitled, resident on a passive range of motion (PROM) was reviewed on 08/01/18 at 7:15 AM. An entry dated 07/06/18 noted Resident #10 was on the PROM program (passive range of motion) for his hips knees and ankles. There was no care plan entry for Resident #10's upper extremities. An interview was completed with Occupational Therapist (OT) #221 on 08/01/18 at 7:36 AM. OT #221 reported she had worked with Resident #10. She stated Resident #10 started to have movement of the left arm and We ended up splinting both hands. We could get those on. She stated, We discharged him to restorative to continue range of motion. She stated Resident #10 was discharged (from OT) on 07/09(18). The goal was to have hand splints on an hour a day if he tolerated them. Restorative (nurse aide) put the splints on and took them off. An observation of Resident #10 was completed on 08/01/18 at 8:12 AM. Resident #10 did not have hand splints in place. His fingers were partially flexed and closed approximately half way. On 08/01/18 at 8:31 AM, an interview was completed with Restorative Aide (RA) #5. RA #5 reported she was familiar with Resident #10. I've been working with him about 3 weeks. Right now, we are working on his lower extremities. We were doing upper body, arms, range of motions. He had hand splints. We (restorative aides) were doing the splints. The (floor) aides (nursing assistants) do that now. On 08/01/18 at 8:39 AM, an interview was completed with Nursing Assistant (NA) #34. NA #34 stated she was familiar with Resident #10. I work with his legs, help him stretch some; and his arms, move his arms, (demonstrated abducting and adducting) the shoulders and stretching his fingers. That's about all I do with his arms. Restorative puts splints on his legs and his arms, I don't do that. He has arm splints that go from his elbows down to his hands. A follow up observation of Resident #10 was completed on 08/01/18 at 9:11 AM. Resident #10 was noted to have leg braces on. No hand splints were observed. An interview was completed with Nurse #71 on 08/01/18 at 9:22 AM. Nurse #71 was identified as the unit manager for Resident #10. Nurse #71 said residents were referred to the restorative aide program by therapy staff. She stated residents would be re-evaluated on a schedule that she was not sure of, and a decision would be made on continuing restorative services. She also noted that if a resident had reached their maximum potential, they would be discharged from restorative and I assume we would stop any splints. After reviewing the record of Resident #10, Nurse #71 stated Resident #10 was getting range of motion and splints to his legs, but not to the upper extremities. On 08/01/18 at 9:42 AM, an interview was completed with the Director of Nurses (DON). The DON said, therapy may refer a resident to restorative nursing when therapy is done. We put them on a 4-6 week restorative program and then we re-evaluate. At that time, we may refer them back to therapy, or we may extend the program or do a management program and have the floor nursing assistants pick that (range of motion or splints) up having the floor nurse monitoring. On 07/09(18), (OT #221) did a therapy to restorative evaluation. It said the resident (#10) should get range of motion (ROM) to upper extremities with hand splints. When therapy does the evaluation, it goes into the computer and I (DON) see it under Progress Evaluations. I would write the physician's orders [REDACTED]. For the 07/09(18) referral, I don't see the order was written and no task was done. It wasn't put on restorative's list of things to complete. We would update the care plan when we write the order. He doesn't have an order, a task and no updated care plan for the hand splints. The hand splints would have been hand rolls just in his palms (to prevent contractures of the fingers).",2020-09-01
809,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2018-08-01,914,E,0,1,68SA11,"Based on observations and staff interviews, the facility failed to ensure privacy curtains in two-bed rooms provided complete visual privacy for residents occupying the bed next to the window. This affected three (Residents #67, #255, and #23) of three sampled residents. The facility census was 102. Findings included: 1. On 07/30/18 at 9:51 AM, an observation was completed of Resident #67's room. Resident #67 resided in a room with two (2) beds. Resident #67 was assigned the bed farthest from the door and next to the window. A privacy curtain was observed in the middle of the room between the two beds. The privacy curtain track was attached to the ceiling. The ceiling track extended from the head of the bed and stopped at a ceiling light fixture approximately 4-5 feet from the opposite wall. There was no privacy curtain track that extended along the foot of the bed to provide full visual privacy when Resident #67 occupied the bed. There was no privacy screen or mechanism observed in the room to provide full visual privacy for Resident #67. 2. On 07/30/18 at 10:23 AM, an observation was completed of Resident #255's room. Resident #255 resided in a room with two (2) beds. Resident #255 was assigned the bed farthest from the door and next to the window. A privacy curtain was observed in the middle of the room between the two beds. The privacy curtain track was attached to the ceiling. The ceiling track extended from the head of the bed and stopped at a ceiling light fixture approximately 4-5 feet from the opposite wall. There was no privacy curtain track that extended along the foot of the bed to provide full visual privacy when Resident #255 occupied the bed. There was no privacy screen or mechanism observed in the room to provide full visual privacy for Resident #255. 3. On 07/30/18 at 2:28 PM, an observation was completed of Resident #23's room. Resident #23 resided in a room with two (2) beds. Resident #23 was assigned the bed farthest from the door and next to the window. A privacy curtain was observed in the middle of the room between the two beds. The privacy curtain track was attached to the ceiling. The ceiling track extended from the head of the bed and stopped at a ceiling light fixture approximately 4-5 feet from the opposite wall. There was no privacy curtain track that extended along the foot of the bed to provide full visual privacy when Resident #23 occupied the bed. There was no privacy screen or mechanism observed in the room to provide full visual privacy for Resident #23. An interview was completed with Nursing Assistant (NA) #34 on 07/31/18 at 8:43 AM. NA #34 stated that she was familiar with Resident #23. There really isn't any way to make it so they aren't seen since the curtain stops at the light. 4. On 07/31/18 at 9:00 AM, an interview was completed with the facility Administrator. The Administrator stated, If a resident wants privacy, we try to put them in a private room. Most residents like the interaction with a roommate and we try and pair them up with a roommate they would get along with. It's never really come up that the privacy curtains were an issue. If a resident is having visitors or wants extra privacy for the day, we try and get the roommate out of the room or tell the roommate and the staff that the resident is asking for privacy. The Administrator acknowledged the privacy curtain could not provide visual privacy for the resident in the bed next to the window.",2020-09-01
810,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,637,D,0,1,QLU411,"**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 Minimum Data Set (MDS) when Resident #100 elected to participate in a Hospice program. This was true for one (1) of one (1) residents reviewed for the care area of death. Resident identifier: #100. Facility census: 101. Findings included: a) Resident #100 Review of Resident #100's medical records found a Hospice referral and her acceptance into the program on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #100's MDS and found no significant change MDS after the date of admission ([DATE]), to the Hospice Program. Resident #100 expired on [DATE]. Review of the Resident Assessment Instrument (RAI) and Surveyor's interpretative guidelines reads: A Significant Change in Status MDS is required when: A resident enrolls in a hospice program . Interview with the Director of Nursing (DON) and Employee #8, Registered Nurse (RN), MDS coordinator on [DATE] at 5:58 PM, she verified Resident #100 should have had a significant change MDS done within 14 days of her election to participate in a hospice program. The DON further verified the significant change MDS was not completed timely.",2020-09-01
811,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,641,D,0,1,QLU411,"Based on record review and staff interview, the facility failed to ensure Resident #82's quarterly Minimum Data Set (MDS) was accurately coded to reflect his refusals of care. The facility also failed to ensure Resident #85's weights were accurately recorded on his MDS. This was true for two (2) of 23 sampled residents. Resident identifier: #82 and #85. Facility census: 101. Findings included: a) Resident #82 A review of Resident's #82 medical record found a quarterly MDS with an assessment reference date (ARD) of 06/13/19 found under section E0800. Rejection of Care - Presence and Frequency was coded 0. Behavior not exhibited. A review of Resident #82's Activities of Daily Living (ADL) flow sheet for the MDS look back period of 06/07/19 until 06/13/19 found on 06/08/19 Resident #82 refused a shower. This was not accurately captured on the Quarterly MDS with an ARD of 06/13/19. An interview with Social Worker on 08/20/19 at 1:30 p.m. on 08/20/19 confirmed this MDS was inaccurately coded. He stated that he would look at the residents paperwork and get back to me if he found anything else. b) Resident #85 On 08/19/19 at 2:56 PM, a review of Resident #85's weight records found that Resident #85 had experienced numerous weight changes over an extended period of time. On 08/20/19 at 4:21 PM, Resident #85's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 06/20/19 was reviewed. Section K (nutritional status) of the 06/20/19 MDS indicated that Resident #85 weighed 95 pounds. However, Resident #85's weight records indicated that Resident #85's most recent weight on the ARD of the assessment was 82.4 pounds (82 pounds when rounded per section K instructions). On 08/20/19 at 4:26 PM, Resident #85's quarterly MDS with an ARD of 03/20/19 was reviewed. Section K of the 03/20/19 MDS indicated that Resident #85 weighed 91 pounds. However, Resident #85's weight records indicated that Resident #85's most recent weight on the ARD of the assessment was 88.4 pounds (88 pounds when rounded per section K instructions). On 08/20/19 at 4:28 PM, Resident #85's annual MDS with an ARD of 11/21/18 was reviewed. Section K of the 11/21/18 MDS indicated that Resident #85 weighed 88 pounds. However, Resident #85's weight records indicated that Resident #85's most recent weight on the ARD of the assessment was 89.5 pounds (90 pounds when rounded per section K instructions). During an interview on 08/20/19 at 4:48 PM, the facility's Certified Dietary Manager (CDM) acknowledged that she had incorrectly coded Resident #85's weight on each of the above assessments. She stated, I used the most recent weight, but added that she had mistakenly used the weight closest to when she had completed the assessment and not the weight closest to the ARD for each assessment. The above information was discussed with the facility's Administrator on 08/20/19 at 5:36 PM. No further information was provided prior to exit.",2020-09-01
812,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,656,E,0,1,QLU411,"**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 three (3) of twenty-three (23) residents reviewed had a person-centered comprehensive care plan developed and implemented for Residents #86, #55, and #99. For Resident #86, the facility failed to implement a care plan for resident preferences for activities. For Resident #55, the facility failed to develop a care plan for the resident's fluid restrictions. For Resident #99, the facility failed to develop a care plan for a resident who required oxygen usage. Resident identifiers: #86, #55, and #99. Facility census: 101. Findings included: a) Resident #86 During the initial interview, on 08/19/19 at 11:50 AM, Resident #86 was asked if he participated in activities. Resident #86 informed the surveyor that he did not go to activities because he did not like to only participate in church and bingo. Resident #86 indicted that he enjoyed going outside for an activity and would participate in those activities. Resident #86 was unaware the facility had any outdoor activities other than a cookout he attended in (MONTH) of 2019. Resident #86 noted he did go outside with his wife when she came to visit. Resident #86's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/03/19 noted the resident had a score of Brief Interview for Mental Status (BIMS) of 13. A BIMS score of 13 indicates that the resident is cognitively intact and has capacity. A record review of Resident #86's activities participation log from 07/22/19 to 08/20/19 noted the resident had not participated in any outdoor activities. There was no indication he was invited to outdoor activities and he refused. Review of Residents #86's care plan found a focus/problem: [NAME] prefers to stay in his room but will attend activities of his choice. The goal associated with this problem: Resident will remain self directed in his room and encouraged to attend OOR activities thru next review. Interventions included: -- Calendar provided and displayed in his room with upcoming events -- Family will visit often -- Invite and encourage to attend -- [NAME] enjoys listening to music and being outside On 08/20/19 at 11:02 AM, the surveyor spoke with Employee #49, Activity Director (AD). The surveyor asked Employee #49 what activities were outside. The surveyor was provided a copy of the activity calendar for the month of (MONTH) and August. Employee #49 stated that anything occurring at the gazebo is outside, such as bubble mania, patio pals, popsicles on the gazebo, and the ice cream social; however, the activity calendar did not indicate the location of all the outdoor activities. The calendar did not indicate bubble mania, patio pals, etc. was being held on the gazebo. AD #49 was unable to provide any evidence the resident was aware of or invited to any outdoor activities. AD #49 said she doesn't keep record of activities the resident was invited to and refused. We need to do a better job with that. The Administrator and Director of Nursing (DON) were informed of the findings on 08/20/19 at 11:58 AM. No further information was provided prior to the end of the exit conference. b) Resident #55 A record review found a physician order [REDACTED]. On 08/20/19 at 1:30 PM, a record review showed the Resident's comprehensive care plan did not contain necessary documentation related to the fluid restriction order by the physician. Record review of the Resident's Plan of Care (P[NAME]) dated 08/08/19, showed the staff documented a total amount of fluid consumed on each of three shifts from 08/08/19 through 08/20/19. However, there were no planned measurable daily fluid quantities documented for a restrictive fluid intake in the Resident's Comprehensive Care Plan. At 8:28 AM on 08/21/19, the Dietary Manager stated she did not have a diet order for fluid restrictions and was unaware the Resident was on a fluid restriction. On 08/21/19 at 8:41 AM, a staff interview with the Director of Nursing (DoN) confirmed that there had been no plan developed to carry out how a fluid restriction would be implement, for example, the amount of fluid intake when the Resident took medications, or the amount of fluid provided during meal times. c) Resident #99 During a family interview on 08/19/19 at 11:56 AM, she said she thinks they take her oxygen off. The oxygen concentrator was running, and the nasal cannula (NC) was on the floor. On 08/19/19 at 12:04 PM, Nurse Aide (NA) #9 stated, she has never seen Resident # 99 wear oxygen. She then picked the tubing up off the floor and placed it in the plastic storage bag hanging on the oxygen concentrator. When it was pointed out by this surveyor to the NA that she had just picked the tubing off the floor, she discarded the tubing. On 08/19/19 at 12:20 PM, NA #9 stated, Resident # 99 has an order for [REDACTED].>During a review of medical records revealed Resident # 99 had an order from her attending Physician for oxygen, dated 07/26/19 as follows: --May have oxygen 2.0 liters/min per via nasal cannula as needed for shortness of breath or chest pain. During an interview on 08/20/19 11:50 AM, Director of Nursing (DON) was asked whether the 07/26/19 oxygen order order was included on the updated 08/06/19 care plan. DON agreed it should have been updated at that time on the care plan to include the need for oxygen for shortness of breath or chest pain. She agreed, that the facility failed to develop a care plan in regard to the oxygen use.",2020-09-01
813,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,657,E,0,1,QLU411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise resident care plans when there were changes in [MEDICAL TREATMENT] care, advance directives, nutritional status, and pressure ulcers. This deficient practice was found for three (3) of 23 sampled residents reviewed during the survey. Resident identifiers: #85, #2, and #151. Facility census: 101. Findings included: a) Resident #85 On [DATE] at 3:11 PM, a review of the medical record found that Resident #85 had been out of the facility receiving a [MEDICAL TREATMENT] treatment. A review of Resident #85's [MEDICAL TREATMENT] care plan on [DATE] at 8:29 AM found the following intervention, last revised on [DATE]: Check and change dressing daily at access site. Document. During an interview on [DATE] at 3:30 PM, Registered Nurse (RN) #114, Resident #85's wound care nurse, stated that nursing home staff did not perform daily dressing changes on Resident #85's [MEDICAL TREATMENT]. RN #114 stated that Resident #85's care plan had not been revised since a previous time when the nursing home staff did perform the dressing changes daily. On [DATE] at 3:41 PM, the above information was discussed with the facility's Administrator. No further information was provided prior to exit. b) Resident #2 Review of the resident's current care plan, revised on [DATE], found a focus/problem: --DNR (Do Not Resuscitate.) The desired outcome: --The resident's DNR-Do not Resuscitate status will be honored thru next review. Interventions included: --Withhold CPR/DNR Record review on [DATE] at 2:06 PM, found the physician orders for scope of treatment (POST) form was executed by the resident on [DATE]. The resident chose do not resuscitate with comfort measures. On [DATE] the resident revoked his current POST form and changed his status to full code. Further review of the medical record found a physician's order, dated [DATE], noting the resident is a full code. On [DATE] at 11:11 AM, the Director of Nursing (DON) confirmed the resident's care plan was not updated to include the resident was now a full code. On [DATE] 02:15 PM, Employee #54, the medical records clerk/ Licensed Practical Nurse (LPN) verified the physician's order did not match the resident information on the POST form. On [DATE] at 09:30 AM, the above information was discussed with the administrator. At the close of the survey, on [DATE] at 3:00 PM no further information was provided. c) Resident #151 1. Nutrition Resident #151 was a re-admission to the facility on [DATE]. Resident #151's initial admission to the facility was [DATE]. A review of Resident #151's weights during the survey indicated she had a significant weight loss. The weights are as follows: --[DATE] - 124 pounds --[DATE] - 118.7 pounds --[DATE] - 116.8 pounds --[DATE] - 114.4 pounds --[DATE] - 111.8 pounds --[DATE] - 113.4 pounds --[DATE] - 112 pounds --[DATE] - 114.4 pounds --[DATE] - 113.6 pounds --[DATE] - 114.2 pounds --[DATE] - 110 pounds --[DATE] - 107.9 pounds A dietary nutritional assessment, completed on [DATE], by the registered dietician found the resident had a significant weight change of 13%. A review of Resident #151's physician orders during the survey noted an order for [REDACTED].#151 also had an order for [REDACTED]. Review of Residents #151's care plan found a focus/problem: --[NAME] is at risk for weight loss due to dysphasia and poor PO intake. The goal associated with this problem: --RNS (restorative nursing services) Dining Program: Goal [NAME] to consume at least 50% of ,[DATE] meals in dining room to help improve PO (by mouth) intake Q (every) day / 7 days per week x 6 weeks. Stop date [DATE]. Interventions included: --Regular diet, mechanical soft texture, regular liquids consistency According to the record, the last revision date for Resident #151's care plan was [DATE]. On [DATE] at 10:01 AM, Employee #87, the Dietary Manager (DM) stated Resident #151 was on restorative dining. DM #87 confirmed there was not an order for [REDACTED]. The DM reviewed the resident's care plan and confirmed the care plan did not include the addition of a nutritional supplement or the use of [MEDICATION NAME] for an appetite stimulant. In addition, the DM confirmed the care plan was not updated to include the resident was no longer a risk for weight loss but is an actual weight loss. The Administrator was made aware of the findings on [DATE] at 10:14 AM. 2. Pressure ulcers Resident #151 was a re-admission to the facility on [DATE]. On [DATE], a random skin sweep assessment was conducted. The assessment noted two areas to Resident #151: --sacrum area, pressure, 2 x 1.5 x 0 (unstagable); and --sacrum area, pressure, 4 x 3.5 x 0 (stage II). A review of Resident #151's physician orders during the survey noted the following physician orders as of [DATE]: --clean stage 2 pressure ulcer to sacrum with wound cleanser, pat dry, apply Venelex to wound bed, cover with border gauze every shift and prn as needed for soiled or missing dressing --clean stage 2 pressure ulcer to sacrum with wound cleanser, pat dry, apply Venelex to wound bed, cover with border gauze every shift and prn every shift for stage 2 pressure ulcer --clean unstagable pressure ulcer to cocyx with wound cleanser, pat dry, apply Venelex to wound bed, cover with border gauze every shift and prn as needed for soiled or missing dressing --clean unstageable pressure ulcer to coccyx with wound cleanser, pat dry, apply Venelex to wound bed, cover with border gauze every shift and prn every shift for unstagable pressure ulcer Review of Residents #151's care plan found a focus/problem: [NAME] has risk for potential to skin integrity related to incontinence, debility, impaired cognition. The goal associated with this problem: --The resident will be free from injury through the review date Interventions included: --Keep skin clean and dry. Use lotion on dry skin. --Turn and reposition every 2 hours while in bed. --According to the record, the last revision date for Resident #151's care plan was [DATE]. Resident #151's care plan has not been updated since [DATE] to indicate Resident #151 has pressure areas on her body. Moreover, Resident 151's care plan has not been updated since [DATE] to indicate the current interventions that the facility is undertaking to address and care for Resident #151's pressure areas. On [DATE] at 11:59 AM, the above findings were discussed with the Administrator, director of nursing (DON), and Employee #41 the Minimum Data Set (MDS) coordinator of findings. No further information was provided.",2020-09-01
814,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,677,D,0,1,QLU411,"Based on record review and staff interview, the facility failed to ensure a dependent resident, Resident #7, received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This was true for one (1) of five (5) residents reviewed for the care area of Activities of Daily Living (ADLs) during the long term care survey process. Resident identifier: #7. Facility census: 101. Findings included: a) Resident #7 During observations of Resident #7 on 08/19/19 at 1:56 p.m. found Resident #7 was not recently shaved. A review of Resident #7's medical record on 8/20/19 at 8:47 a.m. found Resident #7 was scheduled to receive a shower twice weekly on Mondays and Thursdays. A review of his ADL flow sheets from 06/01/19 through present found Resident #7 only received a shower on the following dates: -- 06/04/19 -- 06/07/19 -- 06/11/19 -- 06/13/19 -- 06/21/19 -- 07/05/19 -- 07/16/19 -- 07/19/19 -- 08/02/19 -- 08/06/19 -- 08/15/19 Resident #7 received 11 showers out of a total of 22 possible showers. On 08/20/19 at 1:25 p.m. the Director of Nursing (DON) was interviewed in regards to Resident #7's showers. She stated she would check in the medical records and see if they had any other documentation in regards to Resident #7's showers. An additional interview with the DON at 2:38 p.m. on 08/20/19 she confirmed no other documentation was available, other than the ADL flow sheets, to prove Resident #7 received a shower. She stated the nurses shampoo his hair every Monday and Thursday related to his psoriasis. She did confirm they did not give him a full shower it was just a shampoo of his hair.",2020-09-01
815,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,679,D,0,1,QLU411,"Based on record review, resident interview, resident observation and staff interview, the facility failed to implement an ongoing resident centered activity program for Resident #86. This was true for one (1) of one (1) residents reviewed for the care area of activities. Resident identifier: #86. Facility census: 101. Findings included: a) Resident #86 During an interview, on 08/19/19 at 11:50 AM, Resident #86 was asked if he participated in activities. Resident #86 informed the surveyor he did not go to activities because he did not like to only participate in church and bingo. Resident #86 indicted he enjoyed going outside and would participate in those activities. Resident #86 was unaware the facility had any outdoor activities other than a cookout he attended in (MONTH) of 2019. Resident #86 noted he did go outside with his wife when she came to visit. In addition, Resident #86 stated he does not go on shopping outings, but would enjoy going to shopping outings to window shop. Resident #86 states that his wife will shop for items he wants at times and bring them to him when she visits. Resident #86's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/03/19 noted the resident had a score of Brief Interview for Mental Status (BIMS) of 13. A BIMS score of 13 indicates the resident is cognitively intact and had capacity. A record review of Resident #86's activities participation log from 07/22/19 to 08/20/19 noted the resident had not participated in any outdoor activities. There was no indication he was invited to outdoor activities and he refused. Review of Residents #86's care plan found a focus/problem: --[NAME] prefers to stay in his room but will attend activities of his choice. The goal associated with this problem: --Resident will remain self directed in his room and encouraged to attend OOR activities thru next review. Interventions included: --Calendar provided and displayed in his room with upcoming events --Family will visit often --Invite and encourage to attend --[NAME] enjoys listening to music and being outside On 08/20/19 at 11:02 AM, the surveyor spoke with Employee #49, Activity Director (AD). The surveyor asked Employee #49 what activities were outside. The surveyor was provided a copy of the activity calendar for the month of (MONTH) and August. Employee #49 stated that anything occurring at the gazebo is outside, such as bubble mania, patio pals, popsicles on the gazebo, and the ice cream social; however, the activity calendar did not indicate the location of all the outdoor activities. The calendar did not indicate bubble mania, patio pals, etc. was being held on the gazebo. AD #49 was unable to provide any evidence the resident was aware of or invited to any outdoor activities. AD #49 said she doesn't keep record of activities the resident was invited to and refused. We need to do a better job with that. AD #49 said the facility does go on shopping trips, but Resident #86 was never invited because his wife goes shopping for him and brings in the items he wants. On 08/20/19 at 12:24 PM , Resident #86 was sitting in his room after his lunchtime meal. This surveyor asked Resident #86 if he had participated in any activities the evening of 08/19/19 or any in the day on 08/20/19. Resident #86 stated that he had been out of his room other than for therapy during this timeframe. Resident #86 stated to this surveyor that he would be interested in going to outdoor activities when the staff invited him to come to them. The Administrator and Director of Nursing (DON) were informed of the findings on 08/20/19 at 11:58 AM.",2020-09-01
816,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,684,E,0,1,QLU411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and observation, the facility failed to provide resident-centered care and services, accordance with preferences, goals for care and professional standards of practice to meet each resident's physical, mental, and psychosocial needs. This was true for three (3) of twenty-three (23) residents reviewed during the Long-Term Survey Process (LTSP). Resident #100, the facility transferred the resident to the hospital after the resident/family had requested and completed a new Physician order [REDACTED].#5, the facility failed to follow physician orders [REDACTED].#55, the facility failed to follow the physician order [REDACTED].>Resident identifiers: #100, #5 and #55. Facility census: 101. Findings included: a) Resident #100 Review of Resident #100's medical records found a nurse's note written on 06/11/19 at 2:01 PM, read: Plan of care note. Interdisciplinary team (IDT) review of witnessed incident this a.m. while being assisted to the toilet. She had an episode of becoming weak and losing balance. Her daughter is aware of the continued occurrences of the episodes of [MEDICAL CONDITION] activity and does not wish for the doctor to rule out [MEDICAL CONDITION] (TIA)/ [MEDICAL CONDITIONS]/[MEDICAL CONDITION]. Each event has been brief (seconds) in duration and involves resident becoming weak. (Resident's name) has a failing pacemaker in place and family does not wish for any treatment or replacement of the battery; as well she does not wish for any intervention or medical research into any cause of the episodes. (Resident's daughter's name) stated, I just want her comfortable, she just needs to fall asleep and not wake up. Reviewed the POST form and continues with current wishes of Do Not Resuscitate (DNR) and Comfort Measures only (CMO), no interventions, do not transfer to hospital. Further review of the nursing notes found a note written on 06/11/19 at 11:39 pm, read: Resident found in floor wrapped in blankets stating she hit her head with a small raised area noted to the right side of head assessed. Returned resident to her bed at this time. Resident went unresponsive 911 was called and transferred to hospital. Review of the emergency room visit on 06/11/19, found a note written by physician read: I spoke with the patient's daughter who is Medical Power of Attorney (MPOA). She states that she is aware that her mother's pacemaker isn't functioning. She was seen by (Cardiologist name) a couple of months ago and they chose not to change her pacemaker battery which was low and not functioning properly. The daughter states that she had told the nursing home (NH) staff and nursing supervisor yesterday morning not to send her to the hospital for a CT scan or anything without notifying her first due to CMO. The daughter is aware that the patient's heart rate is in the 30s-40's and she does not want anything done about it. Interview with the Director of Nursing (DON) on 08/20/19 at 1:15 pm. During this interview the residents medical records were reviewed and she agreed the resident should not have been transferred to the hospital due to the family's wishes for CMO measures. b) Resident #5 A review of Resident #5's medical record at 11:03 AM on 08/20/19 found a physician order [REDACTED]. The resident is scheduled to be weighed every Wednesday and Saturday. A record review of weights measured from 06/01/19 through current found the following occasions when Resident #5 gained more than two (2) pounds (lbs): --07/10/19 - 243.1 lbs --07/13/19 - 247.8 lbs (4.7 lb gain) --07/17/19 - 245.2 lbs --07/20/19 - 248.9 lbs (3.7 lb gain) --07/24/19 - 244.4 lbs --07/27/19 - 247.6 lbs (3.2 lb gain) Further review of the record found no indication Resident #5's attending physician was notified of her weight gain of greater than two (2) pounds on: --07/13/19 --07/20/19, and --07/27/19. An interview with the Director of Nursing (DON) at 1:05 p.m. on 08/20/19 confirmed Resident #5's attending physician was not notified when she experienced a weight gain greater than two (2) pounds as directed by the physician's orders [REDACTED].> c) Resident #55 On 08/20/19 at 1:39 PM, record review showed on 8/8/19 the Resident's primary physician in conjunction with a nephrologist ordered a fluid restriction of 1440 milliliters (ml) per day. At 1:46 PM on 08/20/19, observation of the Resident found a cup of water on the bedside table. Also the resident told this surveyor he keeps the cup filled and drinks from it, All day and all evening. On 08/20/19 at 1:52 PM, Nurse Aide (NA) #40 acknowledged there was a cup of water on the bedside table. NA #40 said, The Resident has capacity and knows how much he can drink each day. At 2:00 PM on 08/20/19, review of the Plan of Care (P[NAME]) Response History disclosed a total amount of fluid intake for each of three shifts was documented from 08/08/19 through 08/20/19. On three of those days, 08/09/19, 08/10/19, and 08/11/19, the Resident consumed more than the limit of 1440 mls. Review of the Resident's current Care Plan found no mention of the Fluid Restriction order nor a specific plan to document actual amounts consumed by the Resident. On 08/21/19 at 8:41 AM, an interview with the Director of Nursing (DON) determined that prior to this survey there had been no plan developed to record the Resident's daily fluid intake. The DON said, as of today there was no plan developed to record the amount of daily intake of fluid. On 08/21/19 at 8:42 AM, the failure of the facility to develop a Care Plan and the failure to specify how the plan would be implemented for fluid restriction was discussed with the Facility Administrator, the DON, and the Assistant Director of Nursing (ADON). At the close of the survey on 08/21/19 at 3:00 PM, no further information was provided.",2020-09-01
817,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,687,D,0,1,QLU411,"Based on record review, family interview, resident interview, resident observation and staff interview, the facility failed to ensure Resident #76 received proper treatment and care to maintain mobility and good foot health, in accordance with professional standards of practice. This was true for one (1) of five (5) residents reviewed for the care area of Activities of Daily Living (ADL) during the long term care survey process. Resident identifier: #76. Facility census: 101. Findings include: a) Resident #76 An interview with Resident #76 and her responsible party at 1:51 PM on 08/19/19, revealed Resident #76 had long thick toe nails and needed to see a podiatrist. The responsible party indicated they have been asking them to get her to a podiatrist to get her toe nails trimmed. She stated they are starting to curl under. A review of Resident #76's medical record at 8:54 AM on 8/20/19 found a form titled, Podiatry Informed Consent to Treat. This form indicated Resident #76 was requesting podiatry services for the following complaints, Toe Nails are long thick and painful and can't be cut with ordinary equipment by self or others. This form was completed on 05/07/19 which was Resident #76's date of admission. An interview with Registered Nurse (RN) #114 the wound care nurse at 9:15 AM on 08/20/19 found the podiatrist was last at the facility on 04/19/19 and then he resigned and they have not found a replacement for him yet she said that there is podiatrist here in town that they can send residents if a need arises. She stated Licensed Practical Nurse (LPN) #5 would know more about Resident #76 because he does the wound care on that side of the facility. An observation with LPN #5 of Resident #76 at 9:16 AM on 08/20/19 found the resident had long toenails that were starting to curl under her toes. He agreed the resident needed to be seen by the podiatrist. The resident stated that her toe nails are sore some times and they hurt. When LPN #5 asked what her pain level was on a scale from one (1) to ten (10) the resident stated her pain would be a two (2). An additional interview with LPN #5 at 10:43 AM on 08/20/19 confirmed he set up an appointment with a local podiatrist on 08/27/19 on 1:15 PM. LPN #5 stated he called and got this appointment today and the resident will be seen by the podiatrist on that date. An interview with the Nursing Home Administrator (NHA) on 08/21/19 at 12:00 PM confirmed they knew the residents toe nails were long but they did not know that they were causing her discomfort. He stated that the first we heard of her toe nails causing her discomfort was when LPN #5 was in the room with the surveyor observing her toenails. He stated we have now got her an appointment.",2020-09-01
818,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,692,D,0,1,QLU411,"Based on medical record review and staff interview, the facility failed to assess Resident #46's nutritional needs. This deficient practice was found for one (1) of four (4) residents reviewed for the care area of nutrition. Resident identifier: #46. Facility census: 101. Findings included: a) Resident #46 Record review during the survey found Resident #46 had recently experienced weight loss and was receiving tube feedings as his sole source of nutrition due to an NPO (nothing by mouth) diet order. All documentation from the facility's Registered Dietitian (RD) for the past six (6) months regarding Resident #46's nutritional needs was requested from the facility and provided on 08/21/19 at 10:45 AM. Upon review, Nutrition Assessment's written by the facility's RD were included in the requested information. The most recent two (2) assessments had been signed by the RD on 07/07/19 and 08/10/19, respectively. The 07/07/19 assessment included information regarding the calories, protein, and free water Resident #46's tube feeding regimen provided, but the section labeled, Calculation of Estimated Daily Needs was left entirely blank. The 08/10/19 assessment included neither information regarding the calories, protein, and free water provided by Resident #46's tube feeding regimen nor a calculation of Resident #46's estimated daily needs. During a phone interview on 08/21/19 at 11:27 AM, the facility's RD stated, He's getting a tube feeding, so we know his needs are being met. When asked if she had assessed Resident #46's estimated nutritional needs, she stated, Of course I did. When asked where the calculations were, the RD stated, That's weird that I didn't put that in there. I almost always do. I must have overlooked it. She added, I would have had to have wrote it down. It could have been on a scrap piece of paper. Then she stated, I think I just probably scrolled down to type my note and didn't scroll back up to put it in. At the end of the conversation, the RD stated that she would create addendums to the 07/07/19 and 08/10/19 nutrition assessments to address Resident #46's estimated nutritional needs. On 08/21/19 at 12:07 PM, the above information was discussed with the facility's Administrator. He stated, Thank you.",2020-09-01
819,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,695,D,0,1,QLU411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure the oxygen flow rate was administered as ordered. This was a random opportunity of discovery. Resident identifier: #14. Facility census: 101. Findings included: a) Resident # 14 On 08/19/19 at 11:56 AM, Resident # 14 was in the bed with oxygen concentrator running. The Nasal Cannula was on the floor and the flow rate was set on three (3) liters/per minute. Review of records revealed Resident # 14 had an order for [REDACTED].>--May have oxygen at 2.0 liters/per minute nasal cannula as needed for shortness of breath or chest pain. Dated: 9/18/2018. On 08/20/19 at 1:32 PM, Nurse Aide #111 was in room feeding Resident #14 ice cream. She was asked to provide the rate the oxygen was being delivered. She stated it was set on three (3) liters/per minute. On 08/20/19 at 1:34 PM, Licensed Practical Nurse #122 was asked to witness what the oxygen concentrator was set on. She said, that the flow rate was at three (3) liters/per minute. She was informed that the ordered amount to be delivered was two (2) liters/per minute. She stated, that she will turn it down and let her nurse know. During an interview on 08/20/19 at 1:36 PM, Administrator was informed of findings. He stated that he would talk to the staff about that.",2020-09-01
820,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,758,D,0,1,QLU411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure each residents medication regimen was free from unnecessary [MEDICAL CONDITION] medication. This was true for one (1) of five (5) reviewed for unnecessary medications. Resident #64's medication regimen contained two (2) duplicate [MEDICAL CONDITION] ([MEDICATION NAME] and [MEDICATION NAME]) medication without a documented rational to continue. Resident identifier: #64. Facility census: 101. Findings included: a) Resident #64 Review of Resident #64's medical records found the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #64's medication regimen found on admission the resident was ordered [MEDICATION NAME] 25 mg at night for treatment of [REDACTED]. On 05/31/19, the consultant pharmacist requested for the physician to evaluate the use of duplicate medication of [MEDICATION NAME] and [MEDICATION NAME]. On 06/05/19, the physician responded the consultant pharmacist request as follows: See above. continue Rx (medication). Written in a different handwriting above read: [MEDICATION NAME] 25 mg at night. [MEDICATION NAME] 0.5 mg at night. Behaviors and anxiety approved. On 06/12/19, the psychologist seen Resident #64 in the facility. No mention of what [MEDICAL CONDITION] medications ordered. Written by psychiatrist, continue current [MEDICAL CONDITION] medications. Interview with the Director of Nursing on 08/20/19 at 2:10 pm. Review of Resident #64's medical records could find no rational as to why the resident was receiving duplicate therapy ([MEDICATION NAME] and [MEDICATION NAME]). No further information provided.",2020-09-01
821,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,791,D,0,1,QLU411,"Based on resident interview, observation, record review and staff interview, the facility failed to arrange and/or make an appointment for one (1) of three (3) residents reviewed for dental services. Resident identifier: #23. Facility census: 101. Findings included: a) Resident #23 During an interview on 08/19/19 at 12:14 PM, Resident # 23 pointed out she had no original teeth on the bottom with dentures on the top and bottom. She went on to say, that last month the last real tooth on the bottom started hurting and the dentist pulled it. She reported, that the dentist told her that when she came back in one week, he would re-insert her dentures. She stated, that she has been eating pureed food, which she is not that happy about. She went on to say, that she was wondering how much longer she was going to have to wait. A review of medical records revealed a nursing note dated 07/30/19 at 12:08 PM: --Resident had tooth #22 extracted by dentist on 07/30/19 --Follow up orders for no drinking through straw for 4 days, and to leave gauze pressure pack in place for 1 hour. --Return to dentist in 1 week to re-insert denture. During an interview with Unit Manager #16 on 08/20/19 at 9:38 AM, was asked if there was an appointment made for Resident # 23 after 07/30/19. She was looking in the electronic chart for follow up appointment for Resident # 23 and was unable to find one. She referred me to Laundry Aide/Driver #40. She stated, she is the person who takes the residents for appointments and makes the appointments. During an interview on 08/20/19 at 9:55 AM, Laundry Aide/Driver #40 was asked if Resident #23 had a follow-up appointment with the dentist. She stated, she did not make a follow up appointment, Because the nurses did not put it in so it would kick back. She was asked if that meant that there was a failure to communicate? She said, yes I think so. She went on to say she would make the appointment today. During an interview on 08/20/19 at 10:58 AM, Administrator was informed about the findings regarding Resident #23. He stated, that he will look into it right now.",2020-09-01
822,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,805,D,0,1,QLU411,"Based on test trays and staff interview, the facility failed to serve food of the correct texture to residents receiving a pureed diet. This deficient practice was found during a random opportunity for discovery and had the potential to affect an isolated number of residents. Facility census: 101. Findings included: a) Pureed Test Tray On 08/20/19 at 1:09 PM, a pureed lunch tray containing turkey, mashed potatoes, and peas was tested by surveyors. The pureed peas were found to contain tough skins that had not been fully processed to a smooth texture. On 08/20/19 at 1:12 PM, the facility's Certified Dietary Manager (CDM) tasted the pureed peas and agreed that they were not the appropriate texture. The CDM stated that kitchen staff did not cook the peas long enough before pureeing them. The above findings were discussed with the facility's Administrator on 08/20/19 at 3:41 PM. No further information was provided prior to exit.",2020-09-01
823,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,806,D,0,1,QLU411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, sureyor observations and staff interview, the facility failed to provide food that accomodates the resident's preference for one (1) resident. This was a random opportunity for discovery. Resident identifier: #86. Facility census: 101. Findings included: a) Resident #86 During the initial interview, on 08/19/19 at 11:50 AM Resident #86 stated that he did not like peas and garlic and the facilty kept sending him items that he did not like on his mealtime tray. Resident #86 further stated that the staff set that[***]on my plate everyday and I don't eat. I just leave that on my tray and send it back. Resident #86's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/03/19 noted the resident had a score of Brief Interview for Mental Status (BIMS) of 13. A BIMS score of 13 indicates that the resident is cognitively intact and has capacity. On 08/20/19 at 09:17 AM this surveyor spoke with Employee #87 regarding Resident #86's likes and dislikes. Employee #87, the dietary manager (DM) provided a copy of Resident #86's tray card. The tray card did not indicate any likes or dislikes. This surveyor asked DM #86 to accompany this surveyor to Resident #86's room to note resident's meal preferences. Employee #87 obtained her assessment tool. On 08/20/19 at 09:19 AM, Employee #87 interviewed Resident #86 with surveyor present. Employee #87 asked Resident #86 his preferences for meals, vegetables, and various beverages. Resident #86 indicated his likes and dislikes of various items. Resident #86 indicated that he did not like the following food and beverage items including but not limited to garlic, broccoli, peas, asparagus, cauliflower, tomato juice, and V8 juice. On 08/20/19 at 11:58 AM, the above issues were discussed with both the Adminsitrator as well as the Director of Nursing (DON) of findings for resident preferences. On 08/20/19 at 12:20 PM, the Adminsitrator provided a dietary screen for Resident #86 that was completed on 04/02/19. This screen states under likes and dislikes that tray card system was updated. The assessment does not state whether Resident #86 had any likes or dislikes. Furthur review of Resident #86's tray card system found no likes or dislikes were present on the current tray card.",2020-09-01
824,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,838,F,0,1,QLU411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility assessment and staff interview, the facility failed to ensure the facility assessment included the number of staff required to provide resident care, the types of training and competencies required to provide care; the facility's training program for staff; the physical plant equipment required to provide care; evaluation of any contracts, memorandums of understanding including third party agreements for the provision of goods, services or equipment to the facility during both normal operations and emergencies. The facility assessment failed to address the process for overseeing these services and how those services will meet resident needs and regulatory, operational, maintenance, and staff training requirements, health information technology resources, such as managing resident records and electronically sharing information with other organizations. This had the potential to affect all residents at the facility. Facility census: 101. Findings included: a) Facility assessment The facility provided a copy of the facility assessment to the team leader on the date of entrance to the facility on [DATE]. The plan was effective from 4/11/18-4/10/19. On 8/20/19 at 1:46 PM, the facility assessment was discussed with the administrator. The facility tracked information about their resident population; such as: the number of admissions, short stay, long term stays, physical functioning of the population, physical disabilities, acuity, diseases, conditions, etc. The administrator was unable to provide evidence the assessment contained an evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff were available to meet each resident's needs or a competency-based approach to determine the knowledge and skills required among staff to ensure residents are able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice. This also includes any ethnic, cultural, or religious factors that may need to be considered to meet resident needs, such as activities, food preferences, and any other aspects of care identified. The assessment did not contain any information to indicate a review of individual staff assignments and systems for the coordination and continuity of care for residents within and across these staff assignments. The assessment failed to include or address an evaluation of the facility's training program to ensure any training needs are met for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. The assessment did not include an evaluation of what policies and procedures may be required in the provision of care and that these meet current professional standards of practice. The administrator was unable to provide evidence the assessment contained information regarding the physical plant environment to include an evaluation of how the facility needs to be equipped and maintained to protect and promote the health and safety of residents. There was no information to indicate an evaluation of building maintenance capital improvements, or structures, vehicles, or medical and non-medical equipment and supplies was addressed. The assessment failed to include or address the facility's resources which include supplies, equipment or other services necessary to provide for the needs of residents. There was no evidence the assessment of the resident population contributed to identifying the physical space, equipment, assisted technology, individual communication devices, or other material resources that are needed to provide the required care and services to residents. The administrator was unable to provide evidence the assessment addressed how the facility will securely transfer health information to a hospital, home health agency, or other providers for any resident transferred or discharged from the facility.",2020-09-01
825,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,842,D,0,1,QLU411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #5 and Resident #9's medical record was complete and accurate. Resident #5 had a low blood sugar on 07/22/19. The Blood sugar was documented as three (3) different values in different sections of the medical record. Also on 07/22/19 Resident #5 received two (2) doses of [MEDICATION NAME] but only one (1) dose was documented on the medication administration record (MAR). For Resident #9 the resident did not include the correct [DIAGNOSES REDACTED]. This was true for two (2) of 23 sampled residents. Resident identifier: #5 and 9. Facility census: 101. Findings included: a) Resident #5 A review of Resident #5 medical record on 08/20/19 at 11:03 a.m. found the following nursing notes: -- 07/22/19 at 10:47 a.m. [MEDICATION NAME] Emergency Inject 1 vial intramuscularly as needed for [DIAGNOSES REDACTED] related to Type 2 diabetes mellitus without complications. Resident showed 30 blood glucose level during 11:00 accu check. [MEDICATION NAME] was administered to left deltoid. Resident BGL (blood glucose level) showed 55 approximately 15 minutes later. Second Dose of [MEDICATION NAME] was administered to the right deltoid. BGL showed 78 approximately 10 minutes later. This note was written by Liscensed Practical Nurse (LPN) #65. -- 07/22/19 6:03 p.m.Situation: During AM accu check resident found to be unresponsive to tactile stimuli. BS (blood sugar) 34, administered [MEDICATION NAME] 1 MG (milligram) IM (intramuscularly) right deltoid. Re check of BS after 10 minutes, reading 55. Not responding to tactile stimuli. Administered second dose of [MEDICATION NAME] 1 mg IM left Deltoid. Within 10 minutes (First Name of Resident #5) was opening eyes and verbally communicating, mild shaking of hands noted. HOB (head of bed) elevated 45 degrees angle. Fresh water given. Tolerated well. RR (Respiration Rate) 16, unlabored. States I feel funny. Becoming more alert with AM care. This note was written by Registered Nurse (RN) #143. Review of the Medication Administration Record (MAR) found Resident #5 received a dose of [MEDICATION NAME] Emergency IM. Resident #5's BS was documented as 33 and the site of administration was documented as the Left Shoulder. There was no documentation on the MAR to indicate Resident #5 received the second dose of [MEDICATION NAME] that was mentioned in both nurses notes regarding Resident #5's hypoglycemic episode. It should be noted Resident #5's blood sugar was documented at 30, 33, 34 all referring to the same Blood Sugar reading. An interview with the Director of Nursing (DON) at 1:05 p.m. on 08/20/19 confirmed the errors in documentation of the Blood Sugar level and confirmed the second dose of [MEDICATION NAME] was not documented on the MAR and should have been. b) Resident #9 A review of Resident #9's medical record on 08/20/19 at 03:06 PM, found a physician order [REDACTED]. Give 1 tablet by mouth at bedtime related to major [MEDICAL CONDITION], single episode, unspecified. A review of Resident #9's medical record discovered a dietary note dated 01/26/19. Resident #9 was noted to have a weight loss of 11.5 pounds, totaling an 8% weight loss, over the past 3 weeks. A review of the medical record reveled the following notes: -- Weight warning note dated 02/04/19. The note stated [NAME] continues on weekly weights due to weight loss. Her weight is gradually stabilizing. She remains about IBW (ideal body weight). She continues on RNS (Restorative Nursing Services) Dining and is doing well. She is on Nutritional supplements BID (two times a day), multivitamin Q (every) day, and [MEDICATION NAME] Q hs (at bedtime) for appetite stimulant. RD (Registered Dietician) and doctor aware, continue current P[NAME] (plan of care). On 08/20/19 at 05:09 PM, the Director of Nursing (DON), stated [MEDICATION NAME] was ordered for weight loss as an appetite stimulant and referred to the weight meeting note dated 02/04/19. The DON stated that the [MEDICATION NAME] 15 mg was for an appetite stimulant and not for a [MEDICAL CONDITION]. On 08/21/19 at 08:20 AM, spoke with the Administrator regarding the findings of Resident #9's physician order [REDACTED].",2020-09-01
826,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,880,F,0,1,QLU411,"Based on observation and staff interview, the facility failed to establish and maintain an effective infection control policy. This deficient practice has the potential to affect all residents residing in the facility. The facility failed to notify the local health department immediately of a suspected outbreak of a respiratory symptoms and the laundry room and personnel were not following safe handling of laundry. Facility census: 101. Findings included: a) Respiratory Outbreak Review of the infection control tracking found on 08/12/19 an unknown respiratory outbreak was noted and continue throughout the survey (08/19/19 through 08/21/19). Review of the facility's General Outbreak Investigation/Notification Protocol found the definition of a influenza or influenza like illness (respiratory) outbreaks are three (3) or more of respiratory -like illness in a congregate setting within a three (3) day period. The current outbreak began on 08/12/19. Provider's responsibilities: Report suspected outbreaks immediately by phone to the local health department in the jurisdiction where the outbreak is identified. and collaborate with the local health department to institute appropriate control measures. Report to the health department was made after this surveyor inquired when the health department was notified. Residents was noted to be on the hallways with no meals and/or activities being provided in the main dining room. Unknown how long this practice was in place. Few residents were noted to congregate at the front door. Interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 08/21/19 at 9:30 am. During this interview it was determined the facility had not notified the local health department until after our entrance on 08/19/19. The residents had been on the above mentioned controls since 08/14/19. Incomplete data line listing was reviewed and difficult to determine the amount of residents with symptoms. Two cultures were provided on 08/20/19 which indicates positive for rhinovirus. No further information provided. b) Laundry Room During a tour of the laundry room on 08/20/19 at 1:41 PM, Housekeeping Supervisor (HS) #40 was asked about the many dust mop, mop heads, and cleaning towels hanging in the soiled laundry room. She stated, that they store them there. It was explained that clean items should not be stored in the soiled laundry room. Administrator was in the laundry room at the time and was in agreement. During an interview 08/20/19 at 1:45 PM, Laundry Aide #71 was asked about what her routine is for sorting the laundry and loading the washing machine. She stated, that she gets the soiled laundry and brings into the soiled side of and puts gloves only on to sort and load the washer. She was asked if she had any gowns or aprons in the laundry room to wear. HS #40 said, that they never have had any and they have never used them. During an interview on 08/20/19 at 2:00 PM, Administrator said, that they do not sort the laundry they open the bags inside the washer, and the staff is trained not to allow their clothing to touch the laundry soiled or clean. He provided a facility policy, titled, Infection Control states, that the facility will provide handwashing facilities and products as well as PPE. He was asked for a copy of the education the laundry staff was given. On 08/20/19 at 3:14 PM, Administrator and myself made a return visit to the laundry room Laundry aide #71 was folding clean laundry against the front of her shirt upon entering the room. Which was pointed out to the Administrator. He at that point said, I concede, I see why they should wear gowns or aprons and I need to update the policy as well. Laundry Aide #71 said, I don't think I had it up against me. Administrator said, Yes, you did. On 08/20/19 at 4:00 PM, Administrator was informed that the deficient practice that will be sited, will be for the clean items hanging in the soiled laundry room and the staff member folding clean laundry against her clothing.",2020-09-01
827,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2017-03-22,154,D,0,1,ZQ9211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and record review it was determined the facility failed to ensure two (2) of five (5) residents reviewed for unnecessary medications who received psychoactive medications were informed of the risks and benefits of psychoactive medications. Failure to provide residents and/or the legal representative information regarding psychoactive medications placed the residents at risk to not be fully informed about their care and potential alternate treatment options. Resident identifiers: #35 and #113. Facility census: 85. Findings include: a) Resident #35 Review of physician orders, on 03/21/17 at 10:15 a.m., revealed Resident #35 received the anti-psychotic medication, [MEDICATION NAME], and the anti-depressant medication, [MEDICATION NAME], daily since 09/09/16. On 03/21/17 at 10:25 a.m., review of the Minimum Data Set (MDS) with an Assessment Reference Date of 02/04/17 revealed the resident had moderately impaired cognitive skills. In an interview, on 03/21/17 at 11:35 a.m., Resident #35 was unable to state any of the medications she received nor what she took them for. Review of the resident's record, on 03/21/17 at 10:43 a.m., revealed a paper form entitled Psychotherapeutic Medication Administration Disclosure. The form included different classifications of psychoactive medications, their benefits, adverse reactions and special concerns for staff to select based on the resident's assessed care needs. While someone had circled the anti-psychotic medication [MEDICATION NAME], the form failed to identify the anti-depressant [MEDICATION NAME]. There were no signatures from the resident, the resident's representative, or facility staff, nor was there any indication verbal consent was obtained. There was no date on the form. In an interview, on 03/21/17 at 2:25 p.m., the Assistant Director of Nursing (ADON) #79 stated the hard copy of the Medication Administration Disclosure should be in the chart under the consent tab. She explained this was the facility's evidence the resident, or their representative, was informed about the use of the medication and it's risks and benefits. She reviewed the record, determined the only copy in it was blank, and stated she would check the thinned chart. She explained the admitting nurse, or the nurse who obtained the physician's orders [REDACTED]. At 2:35 p.m. ADON #79 returned and stated she reviewed the thinned chart and progress notes and was unable to locate any indication the resident or the resident's representative had been provided information regarding the use of, including risks and benefits, of the [MEDICAL CONDITION] medications. b) Resident #113 Review of physician orders, on 03/21/17 at 1:35 p.m., revealed Resident #113 received the anti-depressant [MEDICATION NAME], since 05/04/16. The orders also indicated the resident received the anti-psychotic medication [MEDICATION NAME], since 05/03/16, with a decrease in dose on 12/14/16 and an increase back to the original dose on 12/19/16. Review of the MDS with an ARD of 03/07/17, on 03/21/17 at 2:00 p.m., revealed the resident had severely impaired cognitive skills. In an interview, on 03/21/17 at 11:35 a.m., Resident #113 was unable to state any of the medications she received nor was she able to report what she took them for. Review of the resident's record, on 03/21/17 at 2:15 p.m., revealed a blank Psychotherapeutic Medication Administration Disclosure. The form had the resident's name written on it, but did not identify the classification of the medications, the benefits, adverse reactions or special concerns related to these medications. The form did not indicate whether the resident, or the resident's representative, had been provided this information. In an interview on 03/21/17 at 2:25 p.m., the ADON #79 reviewed the record and determined the only copy in it was blank. She stated, Well, she is a ward of the state, so. When asked if that meant the facility would not provide information about the medication to the resident's representative, she said, Well, no. She then stated she would check the resident's thinned record. At 2:35 p.m., she returned and stated she was unable to locate any indication the resident's representative had been provided information regarding the risks and benefits of the [MEDICAL CONDITION] medications.",2020-09-01
828,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2017-03-22,282,B,0,1,ZQ9211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and record review, the facility failed to implement the care plan as directed for two (2) residents reviewed. For Resident #113, staff failed to follow physician's orders [REDACTED]. The facility failed to ensure Resident #91 received a therapeutic diet as directed. Failure to follow the care plan placed residents at risk not to receive the care they were assessed to require. Resident identifiers: #113 and #91. Facility census: 85. Findings include: a) Resident #113 Review of the resident's care plan, on 03/21/17 at 2:32 p.m., revealed a care plan, last revised on 03/14/17, that identified the resident was an insulin dependent diabetic. A listed intervention was for nursing staff to administer insulin as ordered. Physician orders, reviewed on 03/21/17 at 1:35 p.m., revealed an order for [REDACTED]. --Blood sugar of 0 - 150 = 0 units of insulin --Blood sugar of 151 - 200 = 2 units of insulin --Blood sugar of 201 - 250 = 4 units of insulin --Blood sugar of 251 - 300 = 6 units of insulin --Blood sugar of 301 - 350 = 8 units of insulin The (MONTH) (YEAR) Medication Administration Record (MAR), reviewed on 03/22/17 at 9:15 a.m., revealed staff administered an inaccurate dose of insulin on the following dates: -On 02/13/17 at 6:00 a.m., blood sugar was 201 and 2 units of insulin were given instead of the 4 units ordered; --On 02/04/17 at 4:30 p.m., blood sugar was 172 and it appeared staff documented administering 4 units of insulin (the handwriting made it difficult to decipher) instead of the 2 units ordered; and --On 02/14/17 at 4:30 p.m., blood sugar was 374 and staff administered 6 units instead of the 10 units ordered. In an interview, on 03/22/17 at 9:26 a.m., Assistant Director of Nursing (ADON) #79 reviewed the MAR and verified errors occurred in administering physician order [REDACTED]. b) Resident #91 The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/31/17 indicated Resident #91 required supervision for meals and received [MEDICAL TREATMENT] treatment. The most recent care plan initiated on 01/11/17 was reviewed on 03/22/17 at 1:05 p.m. The care plan indicated the resident had a nutritional concern related to the [DIAGNOSES REDACTED]. On 02/02/17, the care plan was revised to include the following intervention: Provide liberalized renal diet as ordered: No potatoes, beans or bananas, double meat portions with all meals. On 03/22/17 at 12:52 p.m., the resident was observed in the dining room eating lunch. The resident was eating a hamburger sandwich with one patty. The Director of Nursing (DON) #3 stated the resident did not receive double meats. On 03/22/17 at 2:23 p.m., interview with DON #3 stated dietary received the physician order [REDACTED].#58 he stated it was in his notes, but the double meats did not print on the diet card, so the resident did not receive them according to physician's orders [REDACTED]. In an interview, on 03/22/17 at 2:26 p.m., Resident #91 stated she couldn't remember getting double meats on her tray. .",2020-09-01
829,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2017-03-22,309,D,0,1,ZQ9211,"**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 three (3) residents reviewed for unnecessary medications who received the correct dosage of sliding scale insulin according to physician's orders [REDACTED]. Resident identifier: #113. Facility census: 85. Findings include: a) Resident #113 Physician orders, reviewed on 03/21/17 at 1:35 p.m., revealed an order for [REDACTED]. --Blood sugar of 0 - 150 = 0 units of insulin --Blood sugar of 151 - 200 = 2 units of insulin --Blood sugar of 201 - 250 = 4 units of insulin --Blood sugar of 251 - 300 = 6 units of insulin The (MONTH) (YEAR) Medication Administration Record (MAR), reviewed on 03/22/17 at 9:15 a.m., revealed staff administered an inaccurate dose of insulin on the following dates: -On 02/13/17 at 6:00 a.m., blood sugar was 201 and 2 units of insulin were given instead of the 4 units ordered; --On 02/04/17 at 4:30 p.m., blood sugar was 172 and it appeared staff documented administering 4 units of insulin (the handwriting made it difficult to decipher) instead of the 2 units ordered; and --On 02/14/17 at 4:30 p.m., blood sugar was 374 and staff administered 6 units instead of the 10 units ordered. In an interview on 03/22/17 at 9:26 a.m., Assistant Nursing Director Staff 79 reviewed the Medication Administration Record and acknowledged the errors. She stated she interpreted the 02/04/17 administration as 4 units and agreed staff should follow physician's orders [REDACTED]. In an interview, on 03/22/17 at 9:26 a.m., Assistant Director of Nursing (ADON) #79 reviewed the MAR and verified errors occurred in administering physician order [REDACTED].",2020-09-01
830,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2017-03-22,325,D,0,1,ZQ9211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and observations, the facility failed to provide a therapeutic diet to one (1) of four (4) residents reviewed for nutrition that received therapeutic diets. Resident identifier: #91. Facility census: 85. Findings include: a) Resident #91 Review of the medical record for Resident #91, on 03/22/17 at 12:52 p.m., revealed the most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 01/31/17, indicated the resident was supervised for meals and received [MEDICAL TREATMENT] treatment. The most recent care plan, initiated on 01/11/17, was reviewed on 03/22/17 at 1:05 p.m. The care plan indicated the resident was at nutritional concern related to: a [DIAGNOSES REDACTED]. On 02/02/17 the care plan was revised to include the following intervention: Provide liberalized renal diet as ordered: No potatoes, beans or bananas, double meat portions with all meals. A nutritional assessment dated [DATE] indicated the resident had a [DIAGNOSES REDACTED]. The physician orders [REDACTED].#91 indicated double meat portions all meals with a [DIAGNOSES REDACTED]. --A liberalized renal diet with a bag lunch at 11:00 a.m. on Tuesday, Thursday, and Saturday to send with [MEDICAL TREATMENT]; --No potatoes, beans or bananas; and --Double meat portions all meals. On 03/22/17 at 12:52 p.m., the resident was observed in the dining room eating lunch. The diet card did not indicate double meat. The resident was eating a hamburger sandwich with one patty. The Director of Nursing (DON) #3 stated the resident did not receive double meats and the diet card was not printed to include double meats. On 03/22/17 at 12:53 p.m., interview with the Registered Dietician #92 verified the resident was on a liberalized diet with double meat for protein. On 03/22/17 at 2:23 p.m., interview with DON #3 stated dietary received the physician order [REDACTED].#58 he stated it was in his notes, but the double meats did not print on the diet card. On 03/22/17 at 2:26 p.m., interview with Resident #91 stated she could not remember getting double meats on her tray. On 03/22/17 at 2:27 p.m., interview with Director of Dining Services #58 stated he received the diet change, but entered the double portions into the system where it appears in notes but doesn't print on the diet card. He corrected the system so it will print now. He could not confirm if the resident ever received double portions. He verified the diet card did not reflect the correct diet which included double meat portions at all meals. On 03/22/17 at 2:31 p.m., during an interview with DON #3 she stated she received information from [MEDICAL TREATMENT] that the resident's [MEDICATION NAME] level from 02/23/17 was 3.4 which is low, normal limits (3.5-5.7), but had improved and the last [MEDICATION NAME] level on 12/27/16 done at facility of 3.2. On 03/22/17 at 2:34 p.m., review of laboratory results, dated 02/23/17 revealed an [MEDICATION NAME] level 3.4 from [MEDICAL TREATMENT] center and a 12/27/16 [MEDICATION NAME] level 3.2, both of which were low. On 03/22/17 at 2:41 p.m., interview with Nurse Practitioner #119 stated she saw the resident on 01/25/17 and wrote new orders for the resident to receive double meat portions at all meals due to low [MEDICATION NAME] levels.",2020-09-01
831,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2017-03-22,364,E,0,1,ZQ9211,"Based on observations, staff interviews and review of the recipes for pureed diets, the facility failed to follow written recipes for pureed diets for one meal. This affected eight (8) of eight (8) residents who received pureed diets. Facility census: 85. Findings include: a) Observations Observations made on 03/21/17 at 11:55 a.m. of Director of Dining Services #58 preparing pureed food for the lunch meal revealed he did not measure the barbeque pork, hot water, or bread crumbs before placing the items into the food processor. The Director of Dining Services #58 was interviewed and he stated the pureed foods were blended to baby food consistency. He verified eight (8) residents received pureed diets. b) Interviews On 03/21/17 at 3:45 p.m., the recipe for puree barbeque pulled pork and bread recipe was reviewed with Director of Dining Services #58. The recipe listed specific measured ingredients and directions for the recipe for each item that needed pureed for the meal. The Director of Dining Services #58 was interviewed on 03/21/17 at 3:45 p.m. and verified the recipe for the barbeque pork was not followed and thickener was not added to the recipe to give it proper consistency.",2020-09-01
833,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2018-05-17,656,D,0,1,H2ZY11,"Based on observation, medical record review, staff interview, and resident interview, the facility failed to ensure the care plans for three (3) of twenty-five (25) residents whose care plans were reviewed addressed the resident's individualized needs. Resident #27's and Resident #6's care plans did not address the residents' reported refusal of showers. Resident #6's care plan did not address the resident's dietary needs due to having no teeth. Resident identifiers: #6, #25, and #37. Facility census: 111. The findings included: a) Resident #27 During a resident interview on 05/17/18 at 10:00 AM, the resident stated showers were not always given as requested and often the resident was told staff were too busy and never returned to help. Review of the resident's care plan dated 03/07/18, revealed Resident #27 required assistance with activities of daily living care. The interventions included a shower preference of Mondays and Thursdays with a notation that Resident #27 often refused showers. According to the resident's medical record, the only shower provided in (MONTH) as of 05/17/18 was one (1) provided on (MONTH) 3, (YEAR). There were no refusals of care marked on the Activities of Daily Living Flow Sheet. During an interview on 05/17/18 at 11:25 AM, the Center Nurse Executive confirmed the ADL sheet revealed only one shower documented with no refusals of showers indicated. An interview with the Administrator on 05/17/18 at 3:22 PM, revealed Resident #27 preferred certain people to assist her and verified refusals had not been documented. It was further stated the resident's care plan did not include Resident #27's preferences or address the resident's refusal of showers. b) Resident #6 Observation of the lunch meal on 05/14/18, revealed Resident #6 received a raw cabbage salad. The resident stated he could not eat hard foods because he had no teeth. A review of Resident #6's care plan found focus area of identifying he was edentulous, but did not include the issue of foods he was not able to chew. An interview with Employee #107, the food service supervisor, on 05/16/18 at 10:25 AM revealed there had been no further evaluation of the foods Resident #6 was having difficulty chewing because of having no teeth. The resident's care plan had not addressed this issue. c) Resident #35 On 05/17/18 11:38 AM, an interview with the director of nursing (DON) revealed the resident had refused showers on 05/12/18 and 05/16/18, but there was no evidence of any attempts to get him to bath later. The issue of the resident's refusal of care and that he would be more receptive to receiving care assisted by certain staff members was not addressed in the care plan.",2020-09-01
835,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2018-05-17,689,L,0,1,H2ZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, resident interview, medical record review, staff interview, and observation of Resident #35, the facility failed to ensure one (1) of three (3) cigarette smokers was capable of safely smoking independently. The resident was observed smoking outside on the sidewalk alone on 05/15/18 at 9:05 a.m. He could not be readily observed by staff inside the building. It was also noted the resident was smoking in an area where a sign was posted prohibiting smoking. The wind was blowing and ashes would blow back on the resident and his clothing. When the ashes would land on his clothing, he appeared unaware of the ashes and made no attempt to brush them off. He was not wearing a smoking apron and there were noticeable holes in the sweatpants he wore. Further investigation found this severely cognitively impaired resident kept his cigarettes and his lighter on his person at all times. These findings were determined to pose a potential for serious harm to the safety and well-being of Resident #35 and to other residents residing in the facility. The Chief Executive Officer (CEO) was informed these findings constituted an immediate jeopardy to the safety and well-being of Resident #35 and to the facility's other residents on 05/15/18 at 9:24 a.m. Written notification of the findings leading to the determination of immediate jeopardy and request for a plan of correction were provided to the CEO. The facility provided an acceptable plan of correction and after verifying implementation of its plan, the immediate jeopardy was abated at 4:30 p.m. on 05/15/18. After removal of the immediate jeopardy, no deficient practice remained for this requirement. Resident identifiers: #35 and the other facility residents. Facility census: 111. Findings included: a) Resident #35 Observations on 05/15/18 at 9:05 a.m., found the resident seated in a wheelchair outside on the front sidewalk smoking a cigarette. No staff were monitoring the resident. Closer observation noted holes in his sweatpants that looked like burn holes from cigarette ashes. Accompanied by another surveyor, the resident was observed again. The wind was blowing and ashes were falling from the cigarette onto his sweat pants. The resident appeared unaware of the ashes falling onto his clothing as he made no attempt to brush the ashes from his clothing. There was no ashtray or receptacle for ashes and cigarette butts near the resident. The area where the resident was smoking had a No smoking allowed within 15 feet of an exit door and near operable windows sign posted. At 9:30 a.m., accompanied by the Chief Executive Officer (CEO), a third observation of Resident #35 found he had moved to another area of the sidewalk. He was not smoking, but the CEO could see the holes in the resident's sweatpants. During the afternoon of 05/15/18, review of the facility's smoking policy, with a revision date of 06/17/17, found the policy directed smoking supplies were to be stored by staff with the resident's name and room number in a suitable cabinet in the nursing station. Additionally, the policy stated in individual special circumstances, the resident might need to wear a smoking apron during smoking. If the resident was cognitively able, the resident could secure all smoking materials in a locked compartment. According to the policy, residents were not allowed to keep lighters or matches. Review of the resident's minimum data set (MDS) assessments, an annual with an assessment reference date (ARD) of 09/09/17 and two (2) subsequent quarterly assessments with ARDs of 12/08/17 and 03/08/17, found his Brief Interview for Mental Status (BIMS) identified he score 6 on all 3 assessments. A score of 6 indicated he had severe cognitive impairment. The quarterly assessments also identified he resisted care 1 to 3 days during the assessment look back periods. The resident's behaviors were addressed in his care plan. Observation on 05/15/18, and by resident and staff interviews, found the resident always kept his lighter and cigarettes on his person in the waistband of his clothing. He did have a compartment in his room to store his smoking materials, but refused to use the compartment A smoking evaluation dated 01/04/18, identified the resident as safe to hold a cigarette, put out ashes, and he did not need a smoking apron. The care plan identified him as being able to smoke according to his smoking assessment which stated he demonstrated safe independent smoking. This care plan, implemented 06/13/16, had the most recent revision on 01/14/18. An interview with the CEO and director of nursing on 05/15/18 at 1:15 p.m. revealed he had a change of condition recently. On 05/04/18, he began pushing and kicking, rejecting care and making disruptive sounds. The CEO and Director of Nursing (DON) reported the resident was known to have paranoid [MEDICAL CONDITION] and behavior changes with increased agitation. Additional interview with the CEO on 05/15/18 at 3:30 p.m., revealed the staff felt the resident had been determined to be safe to smoke independently and had not been seen to be unsafe during his smoking assessment. The resident was known to wear the pants with holes frequently, but the CEO was unaware of the holes in the clothing until the immediate jeopardy was brought to her attention. findings were determined to pose a potential for serious harm to the safety and well-being of Resident #35 and to other residents residing in the facility. The Chief Executive Officer (CEO) was informed these findings constituted an immediate jeopardy to the safety and well-being of Resident #35 and to the facility's other residents on 05/15/18 at 9:24 a.m. Written notification of the findings leading to the determination of immediate jeopardy and request for a plan of correction were provided to the CEO. The facility provided an acceptable plan of correction and after verifying implementation of its plan, the immediate jeopardy was abated at 4:30 p.m. on 05/15/18. After removal of the immediate jeopardy, no deficient practice remained for this requirement. b ) The facility's plan of correction May 15, (YEAR) 12:15pm 1) The Administrator immediately assigned 1:1 supervision to resident #35, on (MONTH) 15, (YEAR) at approximately 9:15am to observe resident for safe use of lighter and smoking materials and to offer/encourage use of safety garment to ensure resident sustains no injury or causes no harm to other residents. He will remain on 1:1 supervision until he is compliant with Smoking Policy. Resident will be encouraged to move 15 foot away from building. Resident #35 will be offered a smoking blanket on his next smoking activity. He and responsible party will be reeducated on smoking policy and desigated area. Administrator identified holes in pants, but nature of cause could not be determined. Resident has very limited clothing and could not determine age of holes. Skin Assessment was attempted, but refused by resident #35. A Skin Assessment had previously been completed on (MONTH) 15, (YEAR), with no skin integrity issues identified. Resident continued to smoke safely, with 1:1 supervision, due to noncompliance with smoking materials and smoking area at 2:30 Social Worker and Administrator explained need for all smoking material and retrieved smoking material at 3:30pm. Staff will continue to provide 1:1 supervision for 24 hours and re-assess at that time. Resident #35, assessment will reflect supervised smoking required, including wearing apron/blanket. 2) At 9:30am the Administrator had all resident rooms checked for smoking materials. No additional smoking material was found at this time. All residents of the facility who smoke have the potential to be effected. No residents of the facility have experienced any negative outcome. The Administrator/designee will re-educate smoking residents/responsible party regarding facilities Smoking Policy on (MONTH) 15, (YEAR), and upon admission and readmission. 3) The Administrator/designee will re-educate all center staff to ensure residents smoking supplies are secured at all times, including lighters, with a post-test to validate understanding, on (MONTH) 15, (YEAR). Staff not available during this time frame will be provided re-education including post-test by Practice Development Specialist/Designee upon return to work. New staff during orientation will be provided education including post-test by PDS/designee. 4) Independent resident smoking materials will be maintained in the medication room, on each unit and signed out by resident/staff and signed back in with the nurse/designee at the completion of the smoke break across all shifts, 7 days per week. Audits will be conducted by Director of Nurses/designee daily across all shifts x 2 weeks then 3 x per week x 2 weeks then randomly thereafter to ensure that smoking materials are secured. 5) Trends identified will be reported by the Director of Nurses/designee monthly at the Quality Improvement Committee (QIC) for any additional follow up and/or in servicing until the issue is resolved and randomly thereafter as determined by the QIC committee.",2020-09-01
836,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2018-05-17,745,D,0,1,H2ZY11,"Based on medical record review and by staff interview, the facility failed to ensure one (1) of twenty-five (25) residents received medically-related social services when the resident refused care. This was evident for Resident #35. Census: 111. Findings include: a) Resident #35 Review of the resident's medical record found documentation the resident refused showers on 05/12/18 and on 05/16/18. There was no evidence staff had waited and approached the resident about bathing later. 05/17/18 11:38 AM, interview with the director of nursing (DON) revealed the resident had refused showers on 5/12/18 and 5/16/18, but there was no evidence of any further attempts to get him to bathe later. She stated the normal procedure was for staff to attempt to get the resident to take a shower and then if the resident refused, go back later and offer again. There was no evidence that social services staff had intervened and offered to see why the resident was refusing the care. Additionally, the resident was known to resist care and to refuse medications at times. This had not been addressed by social services, nor included in the care plan to address the behavior of resisting care.",2020-09-01
837,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2018-05-17,805,D,0,1,H2ZY11,"**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 one (1) of twenty-five (25) sampled residents received food in a form to meet the individual's needs. Resident #6, who was edentulous, received foods he was unable to chew. Resident Identifier: #6. Facility census: 111. The findings included: a) Resident #6 Observation of the lunch meal served on 05/14/18, revealed Resident #6 received cabbage slaw. The resident stated he could not chew raw cabbage. He further stated that he received food items for meals and snacks that he was unable to chew because he had no teeth. A review of the resident's medical record on 05/16/18, found the physician's orders [REDACTED]. An additional observation made during the breakfast meal on 05/16/18 noted a package of unconsumed pretzels. When questioned, Resident #6 stated he had received them as a snack and they were too hard to eat without teeth. An interview with Employee #107, the food service supervisor, on 05/16/18 at 9:45 AM revealed Resident #6 received the red cabbage on Monday because he was on a regular consistency diet. Employee#107 confirmed that the cabbage slaw was not finely chopped. Employee #107 said speech therapy would be consulted to re-evaluate the resident's consistency/texture needs. During an interview on 05/16/18 at 3:00 PM, the Administrator said they would look into having soft snacks as opposed to items difficult for some residents to chew.",2020-09-01
838,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2018-05-17,808,D,0,1,H2ZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and medical record, the facility failed to serve therapeutic diets as prescribed by the physician for two (2) randomly observed residents. Resident #5, who was on a renal diet, received a banana. Resident #101 did not receive large portions as ordered until it was brought to the attention of staff. Resident Identifiers: #5 and #101. Facility census: 111. The findings included: a) Resident #5 An observation of the breakfast meal on 05/16/18 at 7:35 AM, revealed Resident #5 received a banana on his tray. The resident told the aide delivering the tray he was not supposed to eat bananas because of being on a [MEDICAL TREATMENT] diet. During an interview on 05/16/18 at lunch time, the resident stated he was not allowed to have certain food items because of having End Stage [MEDICAL CONDITION], but I get them anyway. A review of the resident's medical record on 05/16/18 found a physician's orders [REDACTED]. An interview with Employee #107, the food service supervisor, on 05/16/18 at 9:30 AM, verified Resident #5 received the banana by mistake because, The aide was trying to get the tray line going and looked at the list as a preference instead of an item to withhold from the tray. b) Resident #101 Observations in the dietary department on 05/17/18 at 7:25 a.m., noted dietary staff did not serve the correct food amount as ordered for the resident. The resident was served regular portions as identified on the regular menu rather than large portions. When questioned, the food service manager, who was filling in from a sister facility, verified that was not what a large portion diet was to receive. The tray then had the additional items needed to make it large portions. According to the registered dietitian's approved recommendations, the resident was to have a regular liberalized diet with large portions, ProHeal (a supplement), snacks TID (three times a day) and [MEDICATION NAME] and [MEDICATION NAME] for appetite stimulation for weight gain. The resident had not received the correct portions as required until surveyor intervention.",2020-09-01
839,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2018-05-17,812,E,0,1,H2ZY11,"Based on observation and staff interview, it was found dietary staff had not ensured sanitary techniques were implemented. Equipment needed cleaning, utensils were stored incorrectly, staff did not have proper hair covering, no trashcan was available by the hand sink, and floor tiles were broken. These findings had the potential to affect all residents who received foods from this central location. Census: 111. Findings include: a) During the initial tour of the dietary department with the dietary manager on 05/14/18 at 10:20 a.m., the following issues were noted: - there was no trashcan for the hand sink by the walk-in refrigerator; - a bag of shredded carrots was found in the refrigerator with no date of when opened; - drip pans under the range top had food debris and grease buildup; - the glass oven doors needed cleaned inside and out; and - floors in the walk-in refrigerator had sticky food spills. b) Additional observations on 05/17/18 at 7:25 a.m., verified by the dietary manager from a sister facility, identified the following concerns: - Two (2) male employees were not wearing a beard guard over exposed facial hair; - Flatware was stored in a manner that allowed staff to touch the part of the utensil that would enter the diner's mouth when they retrieved for use; - broken floor tile was found in front of the walk-in refrigerators; - the lowerator plate warmer was dirty and had a rusted appearance. On 05/17/18 at 7:38 a.m., review of the county sanitarian's inspection report dated 10/24/17, revealed the facility was cited for some of the same issues identified during this survey. The need for a trash can and broken tiles were listed in the report.",2020-09-01
840,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2018-05-17,835,F,0,1,H2ZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, policy review, and observation 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. Resident #35 was observed smoking indepently in an unsafe manner and 14 of 15 direct care employees who were employed by a staffing agency and worked in the facility from (MONTH) (YEAR) through (MONTH) (YEAR) did not have crminal background checks through the WV CARES (Clearance for Access Registry and Employment Screening). Both deficient practices had the potention to affect all residents. Employee identifiers: #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #72. Resident identifier: #35. Facility census: 111. Findings include: a) Resident #35 An observation on 05/15/18 at 9:05 a.m., noted Resident #35 seated in a wheelchair outside on the front sidewalk smoking a cigarette. The resident's sweatpants had small holes that appeared to [MEDICAL CONDITION] cigarette ashes. A second observation on 05/15/18 at 9:15 AM gain found the resident smoking a cigarette. The resident seemed unaware that the wind was blowing ashes from the cigarette onto the his sweatpants as he made no effort to brush the ashes from his clothing. There was no ash tray or receptacle to put ashes in while smoking. A sign posted in the area where the resident was smoking said, No smoking allowed within 15 feet of an exit door and near operable windows. As he was smoking in the posted area, there was no ashtray or receptacle for disposal of ashes or cigarette butts. At 9:20 AM a third observation of Resident #35, accompanied by the Center Executive Director (CED) found Resident #35 had moved to another area of the sidewalk. He was not smoking at that time, but the adminstrator could see the holes in the resident's sweatpants. The CED was shown the area with the No smoking allowed within 15 feet of an exit and near operable windows sign where the resident had smoked cigarettes earlier. The facility's smoking policy with a revision date of 06/17/17 stated smoking supplies were to be kept stored by staff with the resident's name and room number in a suitable cabinet in the nursing station. Additionally, the policy stated in individual special circumstances, the resident may need to wear a smoking apron during smoking. If the resident was cognitively able, they could secure all smoking material in a locked compartment. Resident #35 was assessed to have severe cognitive impairment. The policy also identified residents were not allowed to keep lighters or matches. Observations on the afternoon of 05/15/18, and by resident and staff interview, it was found the resident kept his lighter and cigaretts on his person in the waistband of his clothing. He had a compartment in his room to store his smoking materials, but refused to use the compartment. A smoking evaluation, completed on 01/04/18, showed the resident had been identified as safe to hold cigarettes, put out ashes and not to need a smoking apron. The facility completed another smoking evaluation after the issues were identified on 05/15/18. That smoking assessment determined the resident was not safe to smoke and needed supervised smoking as well as a smoke apron. The care plan showed he had been identified as being able to safely smoke independently. The care plan was implemented on 06/13/16 and had the most recent revision of 01/04/17. An Interview with the administrator and director of nursing on the morning of 05/15/18 revealed he had a change of condition on 05/04/18. At this time he was pushing and kicing, rejecting care and making disruptive sounds. Resident #35's medical record revealed a [DIAGNOSES REDACTED]. On 05/17/18 at 3:22 PM an interview with the CED and Center Nurse Executive (CNE) revealed the facility had not noticed the resident had multiple small holes in his sweatpants. Both the CED and CNE verified the facility had not looked at the holes in the resident's pants and observed him smoking unsafely. Both the CNE and CED said the resident wore these pants all of the time and refused to wear other pants. The CED said she could view the resident from her office while he was outside smoking. b) Background Checks On 05/17/18 at 12:50 PM a review of the background checks with Human Resources Manager (HRM) #20 revealed the facility had employed 15 agency employees. Three (3) of the agency employees were LPNs and eleven (11) were NAs. HRM #20 said she would locate the background checks for the agency employees. Further review revealed the following employees and their start dates: -LPN #58 01/03/18. - NA #59 03/19/18 - NA #60 03/26/18 - NA #61 03/28/18 - NA #62 04/02/18 - LPN #63 04/02/18 - NA #64 04/04/18 - NA #65 04/09/18 - NA #66 04/09/18 - NA #67 04/09/18 - NA #68 04/15/18 - NA #69 04/15/18 - NA #70 04/15/18 - LPN #71 04/30/18 - LPN #72 05/07/18 NA #60 had worked 42 days between the dates of 03/27/18 and 05/17/18. LPN #58 had worked 86 days between the dates of 10/16/17 and 05/17/18. NA #59 had worked 38 days between the dates of 03/19/18 and 05/17/18. NA #61 had worked 29 days between the dates of 03/28/18 and 05/17/18. NA #62 had worked 35 days between the dates of 04/02/18 and 05/17/18. LPN #63 had worked 27 days between the dates of 04/02/18 and 05/17/17. NA #64 had worked 34 days between the dates of 04/04/18 and 05/17/18. NA #65 had worked 23 days betwen the dates of 04/09/18 and 05/17/18. NA #66 had worked 27 days between the dates of 04/09/18 and 05/17/18. NA #67 had worked 28 days between the dates of 04/10/18 and 05/17/18. NA #68 had worked 23 days between the dates of 04/15/18 and 05/17/18. NA #70 had worked 13 days between the dates of 04/15/18 and 05/17/18. LPN #72 had worked 2 days between the dates of 05/13/18 and 05/17/18. On 05/17/18 at 6:20 PM, the CED and HRM #20 could not provide any information on the background checks for the employees listed above. They said they were employed by an agency and they were under the impression the agency had checked the criminal backgrounds prior to having them come to work at their facility. They verfiied they had not checked to make sure the agnecy had in fact completed these criminal background checks with the WV CARES system prior to employees working in the buidling. On 05/17/18 at 7:09 PM HRM #20 said she could look in the WV CARES system and see where LPN #72 and NAs #66 and #68 had clearance letters in WV CARES. However, HRM #20 did not know how to find the letters from WV CARES showing these three (3) employees were eligible to work in the facility. The facility only had one (1) agency staff member (LPN #71) who had a letter from WV CARES showing they were eligible to work in the facility.",2020-09-01
841,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,550,E,0,1,LUON11,"Based on observation and staff interview, the facility failed to provide a dignified dining experience for Resident #103, Resident #79, Resident #41, Resident #11, Resident #21, Resident #64, and Resident #211 during the noon time meal in the Maple Dining Room on 06/24/19. Also for Resident #94 the facility failed to provide dignity during wound care. These were both random opportunities for discovery during the Long Term Care Survey at the facility. Resident identifiers: #103, #79, #41, #11, #21, #64, #211, and #94. Facility census: 117. Findings included: a) Maple Dining Room Observations of the noontime meal in the Maple Dining Room began on 06/2419 at 12:45 a.m When the observations began Resident #1, Resident #15, Resident #12 and Resident #42 had their meal and had eaten a large portion of their food. Theses four (4) residents were sitting at three (3) separate tables. Resident #79, Resident #41, Resident #11 were sitting at a another table and did not have their meal when this observation began. They were not served their meal until 1:05 p.m. which was 20 minutes after this observation began. Resident #21 and Resident #64 were also sitting at another table in the Maple Dining room and did not have their meal when this observation began. They were note served their meal until 1:10 p.m. which was 25 minutes after this observation began. Resident #80 and Resident #107 was also sitting at a separate table and did not have their meal when this observation began. They were not served their meal until 1:15 p.m. which was 30 minutes after this observation began. At 12:55 p.m. Resident #103 entered the dining room and sat at the table with Resident #12 who had almost consumed his entire meal by this time. Resident #103 was not served her meal until 1:17 p.m. which was 22 minutes after she entered the dining room. An interview with Nurse Aide #36 at 1:21 p.m. on 06/24/19 confirmed that all residents seated in the dining room are usually served their meal at the same time. She stated, all the trays did not come out together today and they had to keep going to the kitchen to get them. She stated they just recently changed the ways trays come out and she thinks that is what caused the problem. An interview with Registered Nurse #50 at 1:25 p.m. on 06/24/19 confirmed that all residents seated in the dining room should have been served around the same time. She agreed the meals should not have been served 20 to 30 minutes later. She said, they had to go to the kitchen to get a lot of the meals because they did not all come out at the same time. b) Resident #94 During an observation of incontinent care on 06/26/19 at 9:41 AM, peri care by Nurse Aide (NA) #59. NA #59 pulled the curtain between the residents, there was not a curtain at the bottom of the bed, the door was left open. After the care was completed it was revealed that anyone walking by this room would be able to see Resident # 94 from her waist down from hallway. During a brief interview Registered Nurse (RN) #28 and NA #59 were asked about the door being opened during the incontinent care and wound care. RN #28 stated, that they forgot to close the door. They did not know why the curtain at the bottom of the bed was missing. During an interview on 06/26/17 at 11:00 AM, Director of Nursing (DoN) was informed about the observation of the incontinent care and the door not being closed, she had no comment.",2020-09-01
842,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,561,D,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review policy review and staff interview, the facility failed to ensure the resident had the right to make choices about aspects of their life which were important to them. For Resident #106 and Resident #94 the facility failed to allow the resident to make choices about their bathing schedule. For Resident #49 the facility failed to allow her to make choices about her bathing schedule and her religious preferences. This was true for 3 of 5 residents reviewed for the care area of self-determination. Resident identifiers: #49, #106, #94. Facility census: 117. Findings included: a) Resident #49 1. Bathing Schedule: During an interview on 06/24/19 Resident stated, I would like to get more showers, since I have moved over here (Maple Unit) I hardly get any. I am supposed to get at least two (2) a week. Resident was noted to have transferred from Dogwood Unit room [ROOM NUMBER]A to Maple unit room [ROOM NUMBER]B on 05/13/19. Review of Activities of Daily Living (ADL) sheets for Resident #49 revealed Resident received showers for only 4 out of 8 opportunities in May, and 4 out 9 opportunities in June. Record review indicated the shower schedule for when Resident was residing in room [ROOM NUMBER]A in the Dogwood unit was Monday and Thursday. The shower schedule for the Maple Unit while Resident was residing in room [ROOM NUMBER]B was Wednesday and Saturday. After Resident was transferred from room [ROOM NUMBER]A to room [ROOM NUMBER]B on 05/13/19, the Resident went for days in a row from 05/15/19 - 5/18/19 without any type of bathing, and only received two (2) showers (on 06/14/19, and on 06/25/19) thereafter through the end of June. Review of Resident's care plan revealed an active focus point that stated, (Resident's first name) stated that it is important that she has the opportunity engage in daily routines that are meaningful relative to their preferences, with a goal of, Resident will plan and choose to engage in preferred activities daily, and an intervention pertaining to bathing of, It is important for me to choose between a tub bath, shower, bed bath, or sponge bath. On 07/02/19, DON agreed that the Resident did not receive adequate bathing of her choice, and someone should have caught the issue by now by reviewing the ADL sheets. 2. Religious Preferences: During initial screening process on 06/24/19 at 10:56 AM Resident stated she would like to have church every Sunday instead of just once or twice a month. Review of Activities Calendar for the month of (MONTH) 2019 revealed the facility only provided the Resident with one (1) out of (5) opportunities to attend church worship service on Sunday. On 07/01/19 at 8:40 AM during an interview the Activities Director (AD) verified the (MONTH) Activity calendar to only include one (1) opportunity for the Resident to attend church services on Sunday (06/02/19) for the month of June. AD stated activities such as Father's Day celebration, bird watching, and bowling replaced the opportunity for church services on the other Sundays of the month. Review of the Facility's policy REC200 titled Resident/Patient's Choice stated Residents/Patients have the right to participate in leisure and recreation of their choosing. Review of the Facility's policy REC201 titled Spiritual Support stated spiritual and religious activities will be available to residents and their families on a routine basis and include worship services. Review of Resident's care plan revealed an activity focus point that stated, (Resident's first name) stated that it is important that she has the opportunity engage in daily routines that are meaningful relative to their preferences, with a goal the Resident will plan and choose to engage in preferred activities daily, and an intervention that stated:, Encourage and facilitate residents/patients activity preferences daily chronical, bingo, church service, special events, music. During an interview on 07/2/19 at 9:00 AM, social services specialist #96 stated, We (the facility) have piano playing, hymns, and bible study on Tuesdays. But you are right, we don't have actual church services for worship routinely every Sunday. b) Resident #106 1. Bathing Schedule: During an interview on 06/25/19 at 10:30 AM, Resident stated, Not enough showers. I never get bathed on the weekends, they act like I am irritating them. Review of Residents Activity of Daily Living (ADL) sheets for the past two (2) months revealed the Resident was only provided with a bed bath during bathing, no documentation that a shower was ever given or refused. The Resident was not provided with any type of bathing for the following dates: --05/04/19 - Saturday --05/05/19 - Sunday --05/11/19 - Saturday --05/17/19 - Friday --05/18/19 - Saturday --05/19/19 - Sunday --05/24/19 - Friday --05/25/19 - Saturday --05/26/19 - Sunday --06/08/19 - Saturday --06/29/19 - Saturday --06/30/19 - Sunday Review of Dogwood Shower List (unit of which Resident resided) indicated Resident's shower schedule was to be every Tuesday and Friday. Review of Residents care plan revealed an active focus area for bathing that stated: Resident requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to [MEDICAL CONDITION], Dementia, with an intervention of, Provide resident with total assist of 1 for bathing. On 07/02/19 at 9:19 AM, Director of Nursing (DON) agreed that the Resident did not receive any bathing during the weekends as indicated for the dates in (MONTH) and June. No further documentation was provided. c) Resident #94 During an interview with Resident #94 at 3:15 p.m. on 06/24/19 she stated she would like to have at least two (2) showers per week and that is what she is supposed to get but she has only had two (2) showers total since her admission to the facility in February, 2019. Review of the facility's shower schedule at 1:30 p.m. on 06/26/19 found Resident #94 should be showered every Wednesday and Saturday. A review of Resident #94's ADL Flow Sheets for the time period of 02/19/19 (date of residents admission) through current found Resident #94 only received a shower on the following dates: 02/27/19; 04/06/19; 04/17/19 and 05/29/19. Resident had no showers in the Month of 06/2019. Resident #94 had only two (2) documented refusals and only received four (4) of her scheduled 37 showers. An interview with Nursing Home Administrator, and Director of Nursing at 2:06 p.m. on 06/26/19 confirmed Resident #94 had not received her showers as scheduled. They reviewed the ADL documentation and confirmed this would be the only place a shower or refusal would be documented.",2020-09-01
843,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,580,D,0,1,LUON11,"**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 and family and/or responsible party promptly of resident's change of condition (fall). This was a random opportunity for discovery. Resident identifiers: #78. Facility census: 117. Findings included: a) Resident #78 Review of Resident #78's medical records found the resident was admitted on [DATE] to the facility. Additionally, the resident had experienced two (2) falls on 06/22/19 at 1:30 a.m. and 1:00 p.m. Review of the incident reports found: (typed as written) Incident #1- 06/22/19 at 1:30 am- Resident found lying on left side of floor. Assessed for injury and pain, ST (skin tear) to back of bilateral hands, ST to posterior LLE (left lower extremities) and left elbow. Immediate actions taken to protect resident: assessed for injury, pain, assisted to bed and treatments to skin tears. Root cause/conclusion: poor safety awareness. Doctor and family notified on 06/22/19 at 1:00 pm of this incident. Incident #2- 06/22/19 at 1:00 pm- Resident on floor in front of chair laying on stomach. Resident denies pain or discomfort currently. BS (blood sugar) 94 currently. Immediate actions taken to protect resident: assessed for injury skin tears to left forehead, left hand, and right forearm dressings.Root cause/conclusion: resident attempted to get out of chair without assistance and fell on to the floor. Doctor and family notified on 06/22/19 at 1:00 pm of this incident. Review of the transfer report dated 06/22/19 at 2:35 pm, found the resident was transferred to a hospital for evaluation and treatment due to fall (06/22/19 at 1:30 am and 1:00 pm). Resident #78 was readmitted to the facility on [DATE]. Review of the History and Physical (H&P) and Discharge Summary found the following: (typed as written) This [AGE] year-old male who is a resident of a nursing home who presents to the hospital with passing out and falling spells. Patient states that last night he was sitting on the side of bed and he leaned forward and suddenly he was on the floor. He thinks he was out for a second or 2 He then again had the same incident this morning. This morning he was sitting in his chair and may have leaned forward but once again he was on the floor. complaint of a mild headache but no other complaints voiced . The patient had evidence of a of a hematoma over his parietal region (left frontal area above the eye) as well as multiple skin tears of his upper and lower extremities. He did not have any suturable areas skin tear and ecchymosis to the top of his head Interview with the Director of Nursing (DON) on 07/01/19 at 9:00 am. The DON stated after review of Resident #78's medical records it was found the physician and family and/or responsible party was not notified of the 06/22/19 at 1:30 am until after Resident #78 had experienced a second fall at 1:00 pm on 06/22/19. No further information provided.",2020-09-01
844,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,584,E,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure housekeeping services to maintain a sanitary, orderly and comfortable interior. The facility failed to clean fecal matter from the shower room floor on the 200 hall, the floor at the nurse's station on the 300 hall and the privacy curtain in room [ROOM NUMBER]. In addition, one resident had an oxygen concentrator that was overdue for maintenance. This practice affected more than a limited number of residents. Resident identifiers: #47. Facility census 117. Findings included: a) Shower room on the 200 hall During an observation of the shower room on the 200 hall, it was noted that there was dried fecal matter on the shower room floor, it appeared that it had been stepped in and smeared across the floor. On 06/30/19 at 9:50 PM, Licensed Practical Nurse (LPN) #71 verified there were feces on the shower room floor. She was asked when the shower room was last used. She stated, that no one was showered from the 200 hall on this day. She was asked if housekeeping was here today. She stated, that the housekeepers left at 2:00PM. On 07/01/19 at 8:32 AM, Account Manager (AM) #109, stated that she was the manager over housekeeping. She was asked it there was anyone scheduled to work on 06/30/19, and she stated that a Light Housekeeper (a person who cleans the rooms of the residents and sanitizes the shower room). She was asked if the housekeeper would have been expected to clean the fecal matter on the shower room floor. She replied that the NA's should have taken care of that when they had the resident in the shower room. On 07/01/19 at 3:10 PM, Director of Nursing was made aware of the fecal matter found in the shower room. b) 300 Hallway Floor On 07/01/19 at 1:23 PM, observation was made of a dark brown smashed gooey substance that appeared to be fecal matter in the floor in front of the nurse's station on 300 hall. The brown fecal-like matter had been stepped in and spread down hallway with a trail that ended at the doorway of room [ROOM NUMBER]. At 1:24 PM on 07/01/19 the gooey, dark brown substance that appeared to be feces smeared in the floor (of the 300 hallway) was brought to the attention of charge nurse Licensed Practical Nurse (LPN) #51. After inspection of the gooey brown spots on floor, LPN #51 cleaned up the substance with bleach wipes and stated, It does appear to be stool (feces). c) room [ROOM NUMBER] - Privacy Curtains On 06/26/19 at 3:40 PM, privacy curtains in room [ROOM NUMBER] for bed A and B were observed to be poorly kept and contaminated with what appeared to be smeared fingerprints of dark brown reddish substance. During an interview at 3:56 PM on 06/26/19 with Regional Infectious Control Registered Nurse (RN) #130 verified room [ROOM NUMBER] did have dirty privacy curtains at bed A and bed B, with dark brown reddish substance on both curtains that RN #130 stated, may be blood or feces or both. RN #130 further stated, I will have them changed immediately, I agree they need it. d) Resident #47 On 06/26/19 at 3:50 PM, Resident #47's Oxygen Concentrator was found to be overdue for maintenance. The water bottle on the Oxygen Concentrator was dated 06/17/19 and the filter appeared to be dirty. During an interview, Infectious Control Registered Nurse (RN) #47 stated, This (concentrator supplies/filter) should have already been changed, it's supposed to be every 7 days. Review of facility's policy titled, Respiratory Equipment/Supply Cleaning/Disinfection stated within the schedule for supply changes section that oxygen delivery devices should have supplies changed at frequency of every seven (7) days.",2020-09-01
845,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,600,F,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, policy review and staff interview, the facility failed to ensure that all residents were free from abuse and/or neglect. Resident #111 experienced a fall from her bed during a bed bath. Resident #91, #78, #162, #211, #161, #163, #53, #92, #93, #95, #38, #1, #68, #101, #51, #70, #94, #49, #106, #26, #56, #97, #58, #59, #69, #27, #86, #46, #99, #25, #90, #76, #89, #8 and #16 did not receive showers according to resident's preference and/or shower schedule . Resident #162, #53, and #92 did not receive medications in a timely manner. Resident #23 was struck by another resident with no investigation to determine if it was abuse or not. Resident #161 bowel regimen (constipation) was not monitored or addressed. Resident #38 did not receive restorative program as prescribed. This practice has the potential to affect all resident's residing in the facility. This deficient practice was true for thirty-even (37) of forty-one (41) sampled residents. Resident identifiers: #111, #91, #78, #162, #211, #163, #53, #92, #93, #95, #161, #38, #1, #68, #101, #51, #70, #94, #49, #106, #26, #56, #97, #58, #59, #69, #27, #86, #46, #99, #25, #90, #76, #89, #8, #16, and #23. Facility census: 117. Findings included: a) Resident #111 Review of Resident #111's medical records found this resident was admitted to the facility on [DATE] at 6:39 pm, from an acute care facility with [DIAGNOSES REDACTED]. Noted to have impairment of right upper extremity and weakness in the right arm and both legs. Review of the interim care plan dated 02/03/19 found no directions for assistance required to provide Activities of Daily Living (ADL)s which includes bed mobility, transfers, eating, toileting, dressing, grooming, and bathing. Resident #111's experienced a fall on 02/03/19 at 3:30 pm. Resident's progress note states, Resident was being changed by nurse aide at 3:30 pm. Resident was rolling to the right hand side of the bed when the resident rolled herself from the bed to the floor, the bed was raised to waist height as the aide was performing care on the resident. Post fall the resident c/o (complained of) severe left knee and left rib pain. This nurse contacted the on-call physician who gave orders to have resident sent out to the emergency room to be evaluated for potential fractures. Nurse aide who was performing care will complete a statement regarding the incident. Bruise noted on left knee and left cheek. Review of policy for Falls Management reads: Perform neurological assessment for all unwitnessed falls and witnessed falls with head injury This survey requested the statement from the nurse aide providing care for Resident #111 on 02/03/19 at 3:30 pm and neurological checks. No information was provided. emergency room report status [REDACTED]. No fractures or dislocations noted. Resident #111 was seen and examined by the attending physician on 02/04/19. Progress note states, She reports that yesterday she rolled out of bed onto her face during change and hit her face and knee. She was transferred to (name of hospital) where x-rays were done, and they were negative for fracture. She complains of severe pain around the left side of face Mild bruising and tenderness noted around the left periorbital area Resident was evaluated by physical and occupational therapy on 02/04/19. An assessment dated [DATE] at 1:59 performed by a registered nurse (RN) which indicates the resident requires extensive assistance of two or more persons for bed mobility. Interview with the Director of Nursing (DON) on 07/01/19 at 1:10 pm. Resident #111's medical records were reviewed by the DON. She confirmed no neuro checks and nurse aide statement could be located concerning the 02/03/19 incident. She also confirmed the licensed staff had not evaluated the assistance needed for bed mobility and no directions for care was provided to the direct care staff. No further information provided. b) Resident #91 Review of Resident #91's medical records found she was admitted to the facility on [DATE]. Her shower schedule for room [ROOM NUMBER]-A was for every Wednesday and Saturday. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received two (2) of the nine (9) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive showers on the scheduled dates in (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. c) Resident #78 Review of Resident #78's medical records found the resident was admitted to the facility on [DATE]. Shower schedule for room [ROOM NUMBER]-B was for every Tuesday and Friday. Review of the (MONTH) and (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received one (1) of the eight (8) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive showers on the scheduled dates in (MONTH) and (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. d) Resident #162 Review of Resident #162's medical records found the resident was admitted to the facility on [DATE]. Shower schedule for room [ROOM NUMBER]-A was for every Tuesday and Friday. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received none (0) of the four (4) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the Resident did not receive showers on the scheduled dates in (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. Interview with Resident #53 and #92 on 06/24/19 at 11:45 am. During this interview they stated, I don't get my medication due at 9:00 pm until late some nights especially 06/22/19. We also asked for a pain pill and had to wait another hour to get it. We were very frightened due to the resident (#162) had become upset and threw an oxygen cylinder out in the hallway. We were afraid it would blow us up. Review of 162's medical records found no mention of the above incident occurring. On 06/25/19 at 11:00 am the DON was asked about the above incident on evening shift from 06/22/19 thru 06/25/19. She stated, I am not aware of anything occurring on any of these dates. According to an anonymous interview, Resident #162 became upset on the evening of 06/22/19 and did throw her oxygen cylinder out in the hallway. Resident #162 was upset because she felt the nurse was withholding her medication. Review of Resident #162's electronic Medication Administration Audit Report for 06/22/19, found the medication ordered for 9:00 pm (Trazadone, [MEDICATION NAME], Atorvastatin and [MEDICATION NAME]) was not administered by Employee #57, registered nurse (RN) until six (6) hours after the scheduled time at 3:07 am on 06/23/19. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive medications as scheduled on 06/22/19. She confirmed on review of the medication administration times the above mentioned they were documented as given at 3:07 am on 06/23/19. She agreed this was six (6) hours after the scheduled time. A verbal statement dated 07/01/19 with no time documented, from Employee #54, RN read: (typed as written) (Resident #162's name) came out into the hallway requesting pain medication. Nurse informed her that it was not time for her pain medication. (Resident #162's name) then became upset and started to scream and throw things in her room. She threw her water pitcher, threw clothing items, threw her Bi-pap machine across the room, and then proceeded to throw an oxygen cylinder into the hallway. Nurse went into the room and attempted to calm patient explaining to her that she could have her pain medication at 9 pm when it was scheduled and that she is scheduled twice a day dose receiving it at 9 am and 9 pm. After redirecting the patient with further conversation, she calmed down and had on further complaints or behaviors. NA then cleaned her room. The DON on 07/02/19 at 9:00 am stated, I spoke to Employee #54, RN concerning times the medications was documented and she said, she gives all of her medications and then signs all of the medications at one time. When asked if this was the policy of the facility and she said, No. Review of the Medication Administration policy: Medications will be administered and signed immediately after administration .Doses will be administered within one (1) hour of the prescribed time unless otherwise indicated by the prescriber If unable to provide the medication (s) within one hour of prescribed time, refer to Medication errors policy . No further information provided. e) Resident #211 Review of Resident #211's medical records found the resident was admitted to the facility on [DATE]. Shower schedule for room [ROOM NUMBER]-B was for every Tuesday and Friday. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received none (0) of the four (4) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive showers on the scheduled dates in (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. f) Resident #163 Review of Resident #163's medical records found she was admitted to the facility on [DATE]. Her shower schedule for room [ROOM NUMBER]-B was for every Monday and Thursday. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received none (0) of the two (2) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive showers on the scheduled dates in (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. g) Resident #53 Review of Resident #53's medical records found she was admitted to the facility on [DATE]. Her shower schedule for room [ROOM NUMBER]-B was for every Monday and Thursday. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received none (0) of the eight (8) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive showers on the scheduled dates in (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. Interview with Resident #53 and #92 on 06/24/19 at 11:45 am. During this interview they stated, I don't get my medication due at 9:00 pm until late some nights especially 06/22/19. We also asked for a pain pill and had to wait another hour to get it. We were very frightened due to the resident (#162) had become upset and threw an oxygen cylinder out in the hallway. We were afraid it would blow us up. Review of Resident #53's electronic Medication Administration Audit Report for 06/22/19, found the medication ordered for 9:00 pm ([MEDICATION NAME], [MEDICATION NAME] and Klonopin) was not administered by Employee #57, registered nurse (RN) until six (6) hours after the scheduled time at 3:11 am on 06/23/19. No documentation Resident #53 was provided a pain medication (Tylenol) on 06/22/19 or 06/23/19. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive medications as scheduled on 06/22/19. She confirmed on review of the medication administration times the above mentioned they were documented as given at 3:11 am on 06/23/19. She agreed this was six (6) hours after the scheduled time. The DON on 07/02/19 at 9:00 am stated, I spoke to Employee #54, RN concerning times the medications was documented and she said, she gives all of her medications and then signs all of the medications at one time. When asked if this was the policy of the facility and she said, No. Review of the Medication Administration policy: Medications will be administered and signed immediately after administration .Doses will be administered within one (1) hour of the prescribed time unless otherwise indicated by the prescriber If unable to provide the medication (s) within one hour of prescribed time, refer to Medication errors policy . No further information provided. h) Resident #92 Review of Resident #92's medical records found she was admitted to the facility on [DATE]. Her shower schedule for room [ROOM NUMBER]-A was for every Tuesday and Friday. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received one (1) of the eight (8) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive showers on the scheduled dates in (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. Interview with Resident #53 and #92 on 06/24/19 at 11:45 am. During this interview they stated, I don't get my medication due at 9:00 pm until late some nights especially 06/22/19. We also asked for a pain pill and had to wait another hour to get it. We were very frightened due to the resident (#162) had become upset and threw an oxygen cylinder out in the hallway. We were afraid it would blow us up. Review of Resident #92's electronic Medication Administration Record [REDACTED]. No documentation Resident #92 was provided a pain medication (Tylenol) on 06/22/19 or 06/23/19. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive medications as scheduled on 06/22/19. She confirmed on review of the medication administration times the above mentioned they were documented as given at 3:11 am on 06/23/19. She agreed this was six (6) hours after the scheduled time. The DON on 07/02/19 at 9:00 am stated, I spoke to Employee #54, RN concerning times the medications was documented and she said, she gives all of her medications and then signs all of the medications at one time. When asked if this was the policy of the facility and she said, No. Review of the Medication Administration policy: Medications will be administered and signed immediately after administration .Doses will be administered within one (1) hour of the prescribed time unless otherwise indicated by the prescriber If unable to provide the medication (s) within one hour of prescribed time, refer to Medication errors policy . No further information provided. i) Resident #93 Review of Resident #93's medical records found the resident was admitted to the facility on [DATE]. Shower schedule for room [ROOM NUMBER]-B was for every Monday and Thursday. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received one (1) of the eight (8) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive showers on the scheduled dates in (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. j) Resident #95 Review of Resident #95's medical records found the resident was admitted to the facility on [DATE]. Shower schedule for room [ROOM NUMBER]-B was for every Monday and Thursday. On 06/20/19, the resident was transferred to room [ROOM NUMBER]-B and the shower schedule remained on the same days. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received one (1) of the seven (7) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive showers on the scheduled dates in (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. k) Resident #161 (Part 1) Review of the resident's closed medical record found she was admitted to the facility on [DATE] and discharged from the facility on 05/13/19. At 06/26/19 at 3:24 PM, the Residents activities of daily living (ADL) records for (MONTH) and (MONTH) 2019, were reviewed with the director of nursing, (DON) and Registered nurse (RN) #118 the corporate clinical quality specialist. The DON said the Resident's showers days were every Wednesday and Saturday for a total of two showers per week. The resident should have received 5 showers in (MONTH) and 4 showers in May, for a total of 9 showers. The resident received only 3 showers: 04/20/19, 05/08/19 and 05/10/19. The DON confirmed there was no evidence provided to substantiate the resident was offered and refused to take a shower. The DON did not know why the Resident did not receive showers per her shower scheduled. The DON further confirmed she was unaware this resident did not receive showers as directed. (Part 2) Medical record review on 06/26/19 at 1:00 PM, found the resident was admitted to the facility from a hospital on [DATE]. Review of the activities of daily living (ADL) record found the first bowel movement, recorded after admission was on 04/25/19, 16 days after admission. Review of the admission minimum data set (MDS) with an assessment reference date (ARD) of 04/17/19, found the resident was always incontinent of bowel and she required total dependence of two plus staff members for toileting. The resident was unable to walk or transfer herself to a wheelchair. Therefore, the resident could not have toileted herself without staff knowledge. At 3:02 PM on 06/26/19, the Registered Nurse (RN) corporate quality specialist and the director of nursing (DON) reviewed the ADL flow sheet. The DON reviewed the Medication Administration Record [REDACTED]. The DON was unable to provide evidence of any bowel movements documented elsewhere during the time period of 04/10/19 to 04/24/19. At 9:41 AM on 07/01/19, a Registered Nurse (RN) corporate clinical quality specialist RN #131 and the DON reviewed the ADL flow sheet. The DON said she would have expected someone to be monitoring the ADL flow sheets and that someone should have brought this information to the morning meeting so action could be taken. The DON provided a copy of the facility's standing order for constipation: If no bowel movement in three days, give milk of magnesia 30 ml by mouth one dose at bedtime. If no bowel movement within next shift, give [MEDICATION NAME] suppository PR x one If no bowel movement within two hours, give fleet enema If no results from Fleet enema, call physician/advanced practice provider for further orders. At the close of the survey on 07/02/19 at 1:00 PM, no evidence was provided by the facility to indicate the facility was aware there were no bowel movements documented for 16 days and no evidence to substantiate the facility had taken any action to eliminate the residents constipation l) Resident #38 (Part 1) Record review on 06/27/19 at 10:00 AM, revealed an order for [REDACTED]. At 10:22 AM on 06/27/19, the Registered Nurse (RN)#50, who oversees the restorative program, and the restorative aide RA#19, reviewed the restorative nursing record and confirmed there was no evidence to verify the resident received any restorative therapy. RN#50 said RA#19 said they were frequently pulled from the restorative program to work the floor because enough nursing assistants did not show up for work. RA#19 said she was unable to provide restorative nursing services because she was working as a nursing assistant. RN#50 said at times she has to work on the floor as a nurse. On 06/27/19 at 11:44 AM, the administrator said, when restorative is pulled to work the floor the nursing assistants are supposed to provide restorative therapy. The administrator was asked if she was aware there was no documentation of the restorative nursing record. She replied, no. When asked if the facility reviews restorative nursing services during the monthly Quality Assurance and Assessment (QAA) meetings, the administrator said, yes, a report is reviewed. The administrator said RN #50 had not reported any problems with providing restorative therapy. (Part 2) On 07/01/19 at 8:45 AM, the Residents monthly activities of daily living (ADL) flow sheets for April, (MONTH) and (MONTH) 2019 were reviewed. Documentation on the ADL record found Resident #38 received only one (1) shower in (MONTH) and May. and three (3) showers in June. On 07/01/19 at 9:00 AM, the ADL records were reviewed with Registered Nurse (RN) #131, the corporate clinical quality specialist. RN #131 confirmed the resident should receive two showers a week, on Monday and Thursday. RN #131 confirmed she could not find any evidence the showers were offered but not provided due to any refusal by the resident. RN #131 reviewed the ADL record for April, (MONTH) and (MONTH) and verified the documentation noted the resident had only 1 shower in April, 1 shower in May, and 3 showers in (MONTH) 2019. If the resident received showers on Mondays and Thursdays, he should have received a total of nine (9) showers in April, nine (9) showers in (MONTH) and eight (8) showers in June. A total of 26 showers should have been provided, the Resident received only 4 showers. On 07/01/19 at 3:24 PM, the director of nursing (DON) reviewed the ADL records for April, (MONTH) and (MONTH) 2019. The DON was unable to provide any evidence the resident received showers as directed. m) Resident #1 Observations of Resident #1 at 11:48 a.m. on 06/24/19 found the resident to be unshaven. A review of the facility's shower schedule on 07/01/19 at 8:45 a.m. found Resident #1 should be showered every Monday and Thursday. A review of Resident #1's Activity of Daily Living Flow Sheets for the time period of 04/01/19 through current found Resident #1 only received a shower on the following dates: --04/01/19 --04/08/19 --04/09/19 --04/11/19 --04/15/19 --04/26/19 --06/06/19 --06/16/19 The resident received no showers in the month of 05/2019. Resident #1 had no documented refusals of showers and only received showered eight (8) of his scheduled 26 showers in the last three (3) months. An interview with the Director of Nursing at 10:45 a.m. on 07/01/19 reviewed the ADL flow sheets and agreed Resident #1 had not received his showers as scheduled. She stated that when a male resident is showered he should also be shaved. n) Resident #68 Observations of Resident #68 at 3:43 p.m. on 06/24/19 found the resident to be unshaven. A review of the facility's shower schedule on 07/01/19 at 9:00 a.m. found Resident #68 should be showered every Monday and Thursday. A review of Resident #68's ADL Flow Sheets for the time period of 05/09/19 (date of admission) through current found Resident #68 only received a shower on the following dates: --05/24/19 --05/29/19 --06/03/19 --06/07/19 --06/17/19 --06/25/19 Resident #68 had no documented refusals of showers and only received showered six (6) of his scheduled 16 showers since his admission on 05/09/19. An interview with the Director of Nursing at 10:45 a.m. on 07/01/19 reviewed the ADL flow sheets and agreed Resident #68 had not received his showers as scheduled. She also stated that a male resident should be shaved when his showered. o) Resident #101 Observations of Resident #101 at 2:48 p.m. on 06/24/19 found the resident wearing an unclean night gown. A review of the facility's shower schedule on 07/01/19 at 9:05 a.m. found Resident #101 should be showered every Tuesday and Friday. A review of Resident #101's ADL Flow Sheets for the time period of 04/01/19 through current found Resident #101 only received a shower on the following dates: 04/23/19 and 06/17/19. Resident #101 had documented shower refusals documented on the ADL flow sheet on the following days: 04/02/19, 04/19/19 and 05/19/19. Resident had no showers in the Month of 06/2019. Resident #101 had only three (3) documented refusals and only received two (2) of her scheduled 26 showers in the last three (3) months. An interview with the Director of Nursing at 10:45 a.m. on 07/01/19 reviewed the ADL flow sheets and agreed Resident #101 had not received her showers as scheduled. p) Resident #51 Observations of Resident #51 at 3:01 p.m. on 06/24/19 found the resident to be unshaven and his face had patches of dry flaky skin. A review of the facility's shower schedule on 07/01/19 at 8:55 a.m. found Resident #51 should be showered every Wednesday and Saturday. A review of Resident #51's Activity of Daily Living Flow Sheets for the time period of 04/01/19 through current found Resident #51 only received a shower on the following dates: 04/06/19; 04/14/19; 04/26/19 and 05/19/19. The resident received no showers in the month of 06/2019. Resident #51 had no documented refusals of showers and only received showers four (4) of his scheduled 26 showers in the last three (3) months. An interview with the Director of Nursing at 10:45 a.m. on 07/01/19 reviewed the ADL flow sheets and agreed Resident #51 had not received his showers as scheduled. She indicated that males should be shaved when they are showered. q) Resident #70 A review of the facility's shower schedule on 07/01/19 9:20 a.m. found Resident #70 should be showered every Tuesday and Friday. A review of Resident #70's ADL Flow Sheets for the time period of 04/01/19 through current found Resident #70 only received a shower on the following dates: --04/02/19; --04/07/19; --04/09/19; --04/16/19; --04/23/19; --04/30/19; --05/07/19; --05/14/19; --05/21/19; --05/28/19; --06/04/19; --06/18/19; --06/26/19; and --06/30/19. Resident #70 had no documented refusals of showers and only received showered 14 of her scheduled 26 showers in the last three (3) months. An interview with the Director of Nursing at 10:45 a.m. on 07/01/19 reviewed the ADL flow sheets and agreed Resident #70 had not received her showers as scheduled. r) Resident #94 During an interview with Resident #94 at 3:10 p.m. on 06/24/19 she stated she had only received two (2) showers since her admission to the facility in (MONTH) of 2019. She stated that her hair was greasy and she had to get it cut like that. The residents hair did appear to unclean and she had an odor which suggested she had not had a shower recently. Review of the facility's shower schedule at 1:30 p.m. on 06/26/19 found Resident #94 should be showered every Wednesday and Saturday. A review of Resident #94's ADL Flow Sheets for the time period of 02/19/19 (date of residents admission) through current found Resident #94 only received a shower on the following dates: 02/27/19; 04/06/19; 04/17/19 and 05/29/19. Resident had no showers in the Month of 06/2019. Resident #94 had only two (2) documented refusals and only received four (4) of her scheduled 37 showers. An interview with Nursing Home Administrator, and Director of Nursing at 2:06 p.m. on 06/26/19 confirmed Resident #94 had not received her showers as scheduled. They reviewed the ADL documentation and confirmed this would be the only place a shower or refusal would be documented. s) Resident #26 On 07/01/19 at 2:17 PM, a review of Activities of Daily Living (ADL) documents, revealed Resident #26 received zero (0) showers in the month of June. This resident was scheduled to receive two (2) showers a week, on Wednesday and Saturday. This was an opportunity to receive nine (9) showers. On 07/01/19 at 3:10 PM, an interview with Director of Nursing (DoN) confirmed the resident had not received their showers as scheduled. t) Resident #56 On 07/01/19 at 2:20 PM, a review of Activities of Daily Living (ADL) documents, revealed Resident #56 was scheduled to receive two (2) showers a week on Thursday and Sunday, this Resident had the opportunity to receive eight (8) showers for the month of June. This resident received zero (0) showers in the month of June. On 07/01/19 at 3:10 PM, an interview with Director of Nursing (DoN) confirmed the resident had not received their showers as scheduled. u) Resident #97 During a review of Activities of Daily Living (ADL) documents, revealed Resident #97 was scheduled to receive two (2) showers a week on Thursday and Monday, this was nine (9) shower this resident should have received. This resident received two (2) showers in the month of (MONTH) on 06/ 06/19 and 06/17/19. On 07/01/19 at 3:10 PM, an interview with Director of Nursing (DoN) confirmed the resident had not received their showers as scheduled. v) Resident #58 On 07/01/19 at 2:36 PM, a review of Activities of Daily Living (ADL) documents, revealed Resident #58 was scheduled to receive two (2) showers a week on Wednesday and Saturday this was nine (9) shower this resident should have received. This resident received Zero (0) showers in June. On 07/01/19 at 3:10 PM, an interview with Director of Nursing (DoN) confirmed the resident had not received their showers as scheduled. w) Resident #59 On 07/01/19 at 2:39 PM, a review of Activities of Daily Living (ADL) documents, revealed Resident #59 was scheduled to receive two (2) showers a week Tuesday and Friday, this was an opportunity to receive eight (8) showers for the month of June. This resident received one (1) shower on 06/25/19. On 07/01/19 at 3:10 PM, an interview with Director of Nursing (DoN) confirmed the resident had not received their showers as scheduled. x) Resident #69 On 07/01/19 at 2:41 PM, a review of Activities of Daily Living (ADL) documents, revealed Resident #69 was scheduled to receive two (2) showers a week Monday and Thursday. This resident had the opportunity to receive eight (8) showers and received zero (0) showers in June. On 07/01/19 at 3:10 PM, an interview with Director of Nursing (DoN) confirmed the resident had not received their showers as scheduled. y) Resident #27 On 07/01/19 at 3:02 PM, a review of Activities of Daily Living (ADL) documents, revealed Resident #27 was scheduled to receive two (2) showers a week on Monday and Thursday. That was an opportunity to receive eight (8) shower, she received only three (3) out of eight (8), on 06/03/19, 06/10/19 and 06/25/19. On 07/01/19 at 3:10 PM, an interview with Director of Nursing (DoN) confirmed the resident had not received their showers as scheduled. z) Resident #86 On 07/01/19 at 3:39 PM, a review of Activities of Daily Living (ADL) documents, revealed Resident #86 was scheduled to receive two (2) showers a week on Tuesday and Friday. This was an opportunity to have eight (8) however Resident #86 had one (1) shower on 06/12/19. On 07/01/19 at 3:40 PM, an interview with Director of Nursing (DoN) confirmed the resident had not received their showers",2020-09-01
846,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,607,F,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, staff interview, resident interview, and family interview, the facility failed to develop and/or implement policies and procedures to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. This practice has the potential to effect all residents currently residing in the facility. For Residents #1, #68, #101, #51, #70, #94, #26, #56, #97, #58, #59, #69, #27, #86, #46, #99, #25, #90, #76, #89, #8, #16, #161, #38, #49, #106, #91, #78, #162, #211, #163, #53, #92, #93, and #95 the facility failed to identify a pattern of missed showers which led to continued neglect of residents. For Resident #96 the facility failed to report an injury of unknown origin as directed by their policy. For Resident #29 the facility did not thoroughly investigate an allegation of abuse. For Resident #23 the facility failed to investigate a resident to resident altercation to ensure abuse had not occurred. For Resident #111 the facility failed to ensure and accident which resulted in the Resident falling from bed was investigated to rule out abuse and/or neglect. Resident identifiers: #1, #68, #101, #51, #70, #94, #26, #56, #97, #58, #59, #69, #27, #86, #46, #99, #25, #90, #76, #89, #8, #16, #161, #38, #49, #106, #91, #78, #162, #211, #163, #53, #92, #93, #95, #96, #29, #23 and #111. Facility census: 117. Findings included: a) Abuse Policy Concerning Reporting Allegations: A review of the facility's Abuse Prohibition policy with an effective date on 06/01/1996 and a review date of 06/13/18 and a revision date of 07/01/18 found the following in regards to the reporting of abuse and/or neglect: 6. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect the CED (center executive director) or designee will perform the following. 6.1 Enter allegation in the Risk Management System (RMS). 6.2 Report allegations involving abuse (physical, verbal, sexual, mental) not later than two hours after the allegation is made. 6.3 Report allegations involving neglect, exploitation or mistreatment (including injuries of unknown source) an misappropriation of Resident property not later than two hours after the allegation is made if the event results in serious bodily injury. 6.4 Report allegations involving neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property within 24 hours if the event does not result in serious bodily injury The policy does not specify specifically which entities the facility should report these allegations to. An interview with Social Worker #96 at 9:23 a.m. on 07/02/19 confirmed the policy dose not specifically direct the staff to whom they should report allegations of abuse and or neglect. b) Policy Review in Regards to Identifying Abuse and/or Neglect A review of the facility's Abuse Prohibition policy with an effective date on 06/01/1996 and a review date of 06/13/18 and a revision date of 07/01/18 found the following in regards to preventing abuse and/or neglect: 4. Actions to prevent abuse, neglect,exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, will include: 4.2 identifying, correcting, and intervening in situations in which abuse, neglect, and/or misappropriation of resident property is more likely to occur; and . 5. Staff will identify event -- such as suspicious bruising of patients, occurrences, patterns, and trends that may constitute abuse and determine the direction of the investigation. This also includes patient to patient abuse. An interview with the DON at 9:00 a.m. on 07/02/19 confirmed the facility should have identified the trend with residents not receiving their showers and should have put measures in place to prevent further neglect. She agreed the policy directs them to identify such trends. c) Resident #1 Observations of Resident #1 at 11:48 a.m. on 06/24/19 found the resident to be unshaven. A review of the facility's shower schedule on 07/01/19 at 8:45 a.m. found Resident #1 should be showered every Monday and Thursday. A review of Resident #1's Activity of Daily Living Flow Sheets for the time period of 04/01/19 through current found Resident #1 only received a shower on the following dates: --04/01/19; --04/08/19; --04/09/19; --04/11/19; --04/15/19; --04/26/19; --06/06/19 and --06/16/19. The resident received no showers in the month of 05/2019. Resident #1 had no documented refusals of showers and only received showered eight (8) of his scheduled 26 showers in the last three (3) months. An interview with the Director of Nursing at 10:45 a.m. on 07/01/19 reviewed the ADL flow sheets and agreed Resident #1 had not received his showers as scheduled. She stated that when a male resident is showered he should also be shaved. d) Resident #68 Observations of Resident #68 at 3:43 p.m. on 06/24/19 found the resident to be unshaven. A review of the facility's shower schedule on 07/01/19 at 9:00 a.m. found Resident #68 should be showered every Monday and Thursday. A review of Resident #68's ADL Flow Sheets for the time period of 05/09/19 (date of admission) through current found Resident #68 only received a shower on the following dates: --05/24/19; --05/29/19; --06/03/19; --06/07/19; --06/17/19 and --06/25/19. Resident #68 had no documented refusals of showers and only received showered six (6) of his scheduled 16 showers since his admission on 05/09/19. An interview with the Director of Nursing at 10:45 a.m. on 07/01/19 reviewed the ADL flow sheets and agreed Resident #68 had not received his showers as scheduled. She also stated that a male resident should be shaved when his showered. e) Resident #101 Observations of Resident #101 at 2:48 p.m. on 06/24/19 found the resident wearing an unclean night gown. A review of the facility's shower schedule on 07/01/19 at 9:05 a.m. found Resident #101 should be showered every Tuesday and Friday. A review of Resident #101's ADL Flow Sheets for the time period of 04/01/19 through current found Resident #101 only received a shower on the following dates: 04/23/19 and 06/17/19. Resident #101 had documented shower refusals documented on the ADL flow sheet on the following days: 04/02/19, 04/19/19 and 05/19/19. Resident had no showers in the Month of 06/2019. Resident #101 had only three (3) documented refusals and only received two (2) of her scheduled 26 showers in the last three (3) months. An interview with the Director of Nursing at 10:45 a.m. on 07/01/19 reviewed the ADL flow sheets and agreed Resident #101 had not received her showers as scheduled. f) Resident #51 Observations of Resident #51 at 3:01 p.m. on 06/24/19 found the resident to be unshaven and his face had patches of dry flaky skin. A review of the facility's shower schedule on 07/01/19 at 8:55 a.m. found Resident #51 should be showered every Wednesday and Saturday. A review of Resident #51's Activity of Daily Living Flow Sheets for the time period of 04/01/19 through current found Resident #51 only received a shower on the following dates: 04/06/19, 04/14/19, 04/26/19 and 05/19/19. The resident received no showers in the month of 06/2019. Resident #51 had no documented refusals of showers and only received showers four (4) of his scheduled 26 showers in the last three (3) months. An interview with the Director of Nursing at 10:45 a.m. on 07/01/19 reviewed the ADL flow sheets and agreed Resident #51 had not received his showers as scheduled. She indicated that males should be shaved when they are showered. g) Resident #70 A review of the facility's shower schedule on 07/01/19 9:20 a.m. found Resident #70 should be showered every Tuesday and Friday. A review of Resident #70's ADL Flow Sheets for the time period of 04/01/19 through current found Resident #70 only received a shower on the following dates: --04/02/19; --04/07/19; --04/09/19; --04/16/19; --04/23/19; --04/30/19; --05/07/19; --05/14/19 ; --05/21/19; --05/28/19; --06/04/19; --06/18/19; --06/26/19 and --06/30/19. Resident #70 had no documented refusals of showers and only received showered 14 of her scheduled 26 showers in the last three (3) months. An interview with the Director of Nursing at 10:45 a.m. on 07/01/19 reviewed the ADL flow sheets and agreed Resident #70 had not received her showers as scheduled. h) Resident #94 During an interview with Resident #94 at 3:10 p.m. on 06/24/19 she stated she had only received two (2) showers since her admission to the facility in (MONTH) of 2019. She stated that her hair was greasy and she had to get it cut like that. The residents hair did appear to unclean and she had an odor which suggested she had not had a shower recently. Review of the facility's shower schedule at 1:30 p.m. on 06/26/19 found Resident #94 should be showered every Wednesday and Saturday. A review of Resident #94's ADL Flow Sheets for the time period of 02/19/19 (date of residents admission) through current found Resident #94 only received a shower on the following dates: 02/27/19; 04/06/19; 04/17/19 and 05/29/19. Resident had no showers in the Month of 06/2019. Resident #94 had only two (2) documented refusals and only received four (4) of her scheduled 37 showers. An interview with Nursing Home Administrator, and Director of Nursing at 2:06 p.m. on 06/26/19 confirmed Resident #94 had not received her showers as scheduled. They reviewed the ADL documentation and confirmed this would be the only place a shower or refusal would be documented. i) Resident #96 During a family interview with Resident #96's family member on 06/25/19 it was revealed a few weeks previous Resident #96 had a large bruise to her chin and jaw. An interview with Nurse Aide #65 at 3:58 p.m. on 06/26/19 confirmed Resident #96 had a bruise on her on chin she stated, I think it came from the bar where they turned her. When asked if the resident was able to move her self in the bed Nurse Aide #65 stated, She can wiggle her upper body some but is not able to really turn herself in the bed. A review of Resident #96's medical record at 9:00 a.m. on 06/27/19 found two (2) Minimum Data Sets (MDS) with Assessment Reference Dates of 04/05/19 and 06/09/19 which indicated Resident #96 was totally dependent on staff with a two person physical assist for bed mobility. Total dependence is defined on the MDS as full staff performance every time during the entire 7- day period. An interview with the Nursing Home Administrator (NH), the Director of Nursing (DON) and the Registered Nurse Clinical Quality Specialist (RNCQS) #131 at 10:20 a.m. on 06/27/19 revealed the NH and DON were aware of the bruise. The NH indicated she thought the nurse may have mentioned it to her she was not sure exactly how she became aware of it. The NH indicated the Interdisciplinary Team (IDT) rounded on 06/13/19 and observed the bruise and based on how Resident #96 was laying in the bed they concluded she had turned her self over on the grab bar and caused the bruise. When asked if they had completed an incident report or completed can investigation as to how she got the bruise the NH replied, We observed her that morning and based on how she as laying in the bed we concluded that she had turned over on the grab bar. She confirmed they did not get statements from staff nor did they do an incident report. When asked if this was reported as an injury of unknown origin she confirmed it was not. The NH and DON also confirmed there was no notes in Resident #96's record that mentioned the bruise or how it may have occurred. The NH indicated the IDT asked the nurse who was working the day they made rounds and say the bruise to do the incident report and the change of condition in the record but the nurse failed to do so. A review of the facility's Abuse Prohibition policy with an effective date on 06/01/1996 and a review date of 06/13/18 and a revision date of 07/01/18 found the following in regards to the reporting of abuse and/or neglect: 6. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect the CED (center executive director) or designee will perform the following. 6.1 Enter allegation in the Risk Management System (RMS). 6.2 Report allegations involving abuse (physical, verbal, sexual, mental) not later than two hours after the allegation is made. 6.3 Report allegations involving neglect, exploitation or mistreatment (including injuries of unknown source) an misappropriation of Resident property not later than two hours after the allegation is made if the event results in serious bodily injury. 6.4 Report allegations involving neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property within 24 hours if the event does not result in serious bodily injury An interview with the Director of Nursing (DON) at 9:00 a.m. on 07/02/19 confirmed the facility's policy does direct them to report injuries of an unknown source. j) Resident #111 Review of Resident #111's medical records found this resident was admitted to the facility on [DATE] at 6:39 pm, from an acute care facility with [DIAGNOSES REDACTED]. Noted to have impairment of right upper extremity and weakness in the right arm and both legs. Review of the interim care plan dated 02/03/19 found no directions for assistance required to provide Activities of Daily Living (ADL)s which includes bed mobility, transfers, eating, toileting, dressing, grooming, and bathing. Resident #111's experienced a fall on 02/03/19 at 3:30 pm. Resident's progress note states, Resident was being changed by nurse aide at 3:30 pm. Resident was rolling to the right hand side of the bed when the resident rolled herself from the bed to the floor, the bed was raised to waist height as the aide was performing care on the resident. Post fall the resident c/o (complained of) severe left knee and left rib pain. This nurse contacted the on-call physician who gave orders to have resident sent out to the emergency room to be evaluated for potential fractures. Nurse aide who was performing care will complete a statement regarding the incident. Bruise noted on left knee and left cheek. Review of policy for Falls Management reads: Perform neurological assessment for all unwitnessed falls and witnessed falls with head injury This survey requested the statement from the nurse aide providing care for Resident #111 on 02/03/19 at 3:30 pm and neurological checks. No information was provided. emergency room report status [REDACTED]. No fractures or dislocations noted. Resident #111 was seen and examined by the attending physician on 02/04/19. Progress note states, She reports that yesterday she rolled out of bed onto her face during change and hit her face and knee. She was transferred to (name of hospital) where x-rays were done, and they were negative for fracture. She complains of severe pain around the left side of face Mild bruising and tenderness noted around the left periorbital area Resident was evaluated by physical and occupational therapy on 02/04/19. An assessment dated [DATE] at 1:59 performed by a registered nurse (RN) which indicates the resident requires extensive assistance of two or more persons for bed mobility. Interview with the Director of Nursing (DON) on 07/01/19 at 1:10 pm. Resident #111's medical records were reviewed by the DON. She confirmed no neuro checks and nurse aide statement could be located concerning the 02/03/19 incident. She also confirmed the licensed staff had not evaluated the assistance needed for bed mobility and no directions for care was provided to the direct care staff. No further information provided. k) Resident #91 Review of Resident #91's medical records found she was admitted to the facility on [DATE]. Her shower schedule for room [ROOM NUMBER]-A was for every Wednesday and Saturday. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received two (2) of the nine (9) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive showers on the scheduled dates in (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. l) Resident #78 Review of Resident #78's medical records found the resident was admitted to the facility on [DATE]. Shower schedule for room [ROOM NUMBER]-B was for every Tuesday and Friday. Review of the (MONTH) and (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received one (1) of the eight (8) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive showers on the scheduled dates in (MONTH) and (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. m) Resident #162 1. Review of Resident #162's medical records found the resident was admitted to the facility on [DATE]. Shower schedule for room [ROOM NUMBER]-A was for every Tuesday and Friday. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received none (0) of the four (4) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the Resident did not receive showers on the scheduled dates in (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. 2. Interview with Resident #53 and #92 on 06/24/19 at 11:45 am. During this interview they stated, I don't get my medication due at 9:00 pm until late some nights especially 06/22/19. We also asked for a pain pill and had to wait another hour to get it. We were very frightened due to the resident (#162) had become upset and threw an oxygen cylinder out in the hallway. We were afraid it would blow us up. Review of 162's medical records found no mention of the above incident occurring. On 06/25/19 at 11:00 am the DON was asked about the above incident on evening shift from 06/22/19 thru 06/25/19. She stated, I am not aware of anything occurring on any of these dates. According to an annonomas interview, Resident #162 became upset on the evening of 06/22/19 and did throw her oxygen cylinder out in the hallway. Resident #162 was upset because she felt the nurse was withholding her medication. Review of Resident #162's electronic Medication Administration Record [REDACTED]. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive medications as scheduled on 06/22/19. She confirmed on review of the medication administration times the above mentioned they were documented as given at 3:07 am on 06/23/19. She agreed this was six (6) hours after the scheduled time. A verbal statement dated 07/01/19 with no time documented, from Employee #54, RN read: (typed as written) (Resident #162's name) came out into the hallway requesting pain medication. Nurse informed her that it was not time for her pain medication. (Resident #162's name) then became upset and started to scream and throw things in her room. She threw her water pitcher, threw clothing items, threw her Bi-pap machine across the room, and then proceeded to throw an oxygen cylinder into the hallway. Nurse went into the room and attempted to calm patient explaining to her that she could have her pain medication at 9 pm when it was scheduled and that she is scheduled twice a day dose receiving it at 9 am and 9 pm. After redirecting the patient with further conversation, she calmed down and had on further complaints or behaviors. NA then cleaned her room. The DON on 07/02/19 at 9:00 am stated, I spoke to Employee #54, RN concerning times the medications was documented and she said, she gives all of her medications and then signs all of the medications at one time. When asked if this was the policy of the facility and she said, No. Review of the Medication Administration policy: Medications will be administered and signed immediately after administration .Doses will be administered within one (1) hour of the prescribed time unless otherwise indicated by the prescriber If unable to provide the medication (s) within one hour of prescribed time, refer to Medication errors policy . No further information provided. n) Resident #211 Review of Resident #211's medical records found the resident was admitted to the facility on [DATE]. Shower schedule for room [ROOM NUMBER]-B was for every Tuesday and Friday. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received none (0) of the four (4) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive showers on the scheduled dates in (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. o) Resident #163 Review of Resident #163's medical records found she was admitted to the facility on [DATE]. Her shower schedule for room [ROOM NUMBER]-B was for every Monday and Thursday. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received none (0) of the two (2) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive showers on the scheduled dates in (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. p) Resident #53 1. Review of Resident #53's medical records found she was admitted to the facility on [DATE]. Her shower schedule for room [ROOM NUMBER]-B was for every Monday and Thursday. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received none (0) of the eight (8) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive showers on the scheduled dates in (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. 2. Interview with Resident #53 and #92 on 06/24/19 at 11:45 am. During this interview they stated, I don't get my medication due at 9:00 pm until late some nights especially 06/22/19. We also asked for a pain pill and had to wait another hour to get it. We were very frightened due to the resident (#162) had become upset and threw an oxygen cylinder out in the hallway. We were afraid it would blow us up. Review of Resident #53's electronic Medication Administration Record [REDACTED]. No documentation Resident #53 was provided a pain medication (Tylenol) on 06/22/19 or 06/23/19. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive medications as scheduled on 06/22/19. She confirmed on review of the medication administration times the above mentioned they were documented as given at 3:11 am on 06/23/19. She agreed this was six (6) hours after the scheduled time. The DON on 07/02/19 at 9:00 am stated, I spoke to Employee #54, RN concerning times the medications was documented and she said, she gives all of her medications and then signs all of the medications at one time. When asked if this was the policy of the facility and she said, No. Review of the Medication Administration policy: Medications will be administered and signed immediately after administration .Doses will be administered within one (1) hour of the prescribed time unless otherwise indicated by the prescriber If unable to provide the medication (s) within one hour of prescribed time, refer to Medication errors policy . No further information provided. q) Resident #92 1. Review of Resident #92's medical records found she was admitted to the facility on [DATE]. Her shower schedule for room [ROOM NUMBER]-A was for every Tuesday and Friday. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received one (1) of the eight (8) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive showers on the scheduled dates in (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. 2. Interview with Resident #53 and #92 on 06/24/19 at 11:45 am. During this interview they stated, I don't get my medication due at 9:00 pm until late some nights especially 06/22/19. We also asked for a pain pill and had to wait another hour to get it. We were very frightened due to the resident (#162) had become upset and threw an oxygen cylinder out in the hallway. We were afraid it would blow us up. Review of Resident #92's electronic Medication Administration Record [REDACTED]. No documentation Resident #92 was provided a pain medication (Tylenol) on 06/22/19 or 06/23/19. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive medications as scheduled on 06/22/19. She confirmed on review of the medication administration times the above mentioned they were documented as given at 3:11 am on 06/23/19. She agreed this was six (6) hours after the scheduled time. The DON on 07/02/19 at 9:00 am stated, I spoke to Employee #54, RN concerning times the medications was documented and she said, she gives all of her medications and then signs all of the medications at one time. When asked if this was the policy of the facility and she said, No. Review of the Medication Administration policy: Medications will be administered and signed immediately after administration .Doses will be administered within one (1) hour of the prescribed time unless otherwise indicated by the prescriber If unable to provide the medication (s) within one hour of prescribed time, refer to Medication errors policy . No further information provided. r) Resident #93 Review of Resident #93's medical records found the resident was admitted to the facility on [DATE]. Shower schedule for room [ROOM NUMBER]-B was for every Monday and Thursday. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received one (1) of the eight (8) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive showers on the scheduled dates in (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. s) Resident #95 Review of Resident #95's medical records found the resident was admitted to the facility on [DATE]. Shower schedule for room [ROOM NUMBER]-B was for every Monday and Thursday. On 06/20/19, the resident was transferred to room [ROOM NUMBER]-B and the shower schedule remained on the same days. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received one (1) of the seven (7) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive showers on the scheduled dates in (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. t) Resident #161 (Part 1) Review of the resident's closed medical record found she was admitted to the facility on [DATE] and discharged from the facility on 05/13/19. At 06/26/19 at 3:24 PM, the Residents activities of daily living (ADL) records for (MONTH) and (MONTH) 2019, were reviewed with the director of nursing, (DON) and Registered nurse (RN) #118 the corporate clinical quality specialist. The DON said the Resident's showers days were every Wednesday and Saturday for a total of two showers per week. The resident should have received 5 showers in (MONTH) and 4 showers in May, for a total of 9 showers. The resident received only 3 showers: 04/20/19, 05/08/19 and 05/10/19. There was no evidence provided to substantiate the resident was offered and refused to take a shower. (Part 2) Medical record review on 06/26/19 at 1:00 PM, found the resident was admitted to the facility from a hospital on [DATE]. Review of the activities of daily living (ADL) record found the first bowel movement, recorded after admission was on 04/25/19, 16 days after admission. Review of the admission minimum data set (MDS) with an assessment reference date (ARD) of 04/17/19, found the resident was always incontinent of bowel and she required total dependence of two plus staff members for toileting. The resident was unable to walk or transfer herself to a wheelchair. Therefore, the resident could not have toileted herself without staff knowledge. At 3:02 PM on 06/26/19, the Registered Nurse (RN) corporate quality specialist and the director of nursing (DON) reviewed the ADL flow sheet. The DON reviewed the Medication Administration Record [REDACTED]. The DON was unable to provide evidence of any bowel movements documented elsewhere during the time period of 04/10/19 to 04/24/19. At 9:41 AM on 07/01/19, a Registered Nurse (RN) corporate clinical quality specialist RN #131 and the DON reviewed the ADL flow sheet. The DON said she would have expected someone to be monitoring the ADL flow sheets and that someone should have brought this information to the morning meeting so action could be taken. The DON provided a copy of the facility's standing order for constipation: If no bowel movement in three days, give milk of magnesia 30 ml by mouth one dose at bedtime. If no bowel movement within next shift, give [MEDICATION NAME] suppository PR x one If no bowel movement within two hours, give fleet enema If no results from Fleet enema, call physician/advanced practice provider for further orders. At the close of the survey on 07/02/19 at 1:00 PM, no evidence was provided by the facility to indicate the facility was aware there were no bowel movements documented for 16 days and no evidence to substantiate the facility had taken any action to eliminate the residents constipation u) Resident #38 (Part 1) Record review on 06/27/19 at 10:00 AM, revealed an order for [REDACTED]. At 10:22 AM on 06/27/19, the Registered Nurse (RN)#50, who oversees the restorative program, an (TRUNCATED)",2020-09-01
847,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,609,F,0,1,LUON11,"Based on record review, staff interview, family interview, policy review and resident interview, the facility failed to ensure all allegations of abuse and/or neglect was reported to appropriate state agencies. Resident #15, #19, #12, #213, #212, #214, #77, #30, #57, #29 all made allegations of abuse and/or neglect against nurse aides and these were reported to the Nursing Home Program and not the Nurse Aide Program. This was true for 10 of 35 reportable incidents reviewed. For Resident #96 the facility failed to report an injury of unknown origin to appropriate state agencies. This was a random opportunity of discovery. Resident identifiers: #15, #19, #12, #213, #212, #214, #57, #77, #30, #29 and #96. Facility census: 117. Findings included: a) Resident #96 During a family interview with Resident #96's family member on 06/25/19 it was revealed a few weeks previous Resident #96 had a large bruise to her chin and jaw. An interview with Nurse Aide #65 at 3:58 p.m. on 06/26/19 confirmed Resident #96 had a bruise on her on chin she stated, I think it came from the bar where they turned her. When asked if the resident was able to move her self in the bed Nurse Aide #65 stated, She can wiggle her upper body some but is not able to really turn herself in the bed. A review of Resident #96's medical record at 9:00 a.m. on 06/27/19 found two (2) Minimum Data Sets (MDS) with Assessment Reference Dates of 04/05/19 and 06/09/19 which indicated Resident #96 was totally dependent on staff with a two person physical assist for bed mobility. Total dependence is defined on the MDS as full staff performance every time during the entire 7- day period. An interview with the Nursing Home Administrator (NHA), the Director of Nursing (DON) and the Registered Nurse Clinical Quality Specialist (RNCQS) #131 at 10:20 a.m. on 06/27/19 revealed the NHA and DON were aware of the bruise. The NHA indicated she thought the nurse may have mentioned it to her she was not sure exactly how she became aware of it. The NHA indicated the Interdisciplinary Team (IDT) rounded on 06/13/19 and observed the bruise and based on how Resident #96 was laying in the bed they concluded she had turned her self over on the grab bar and caused the bruise. When asked if they had completed an incident report or completed can investigation as to how she got the bruise the NHA replied, We observed her that morning and based on how she as laying in the bed we concluded that she had turned over on the grab bar. She confirmed they did not get statements from staff nor did they do an incident report. When asked if this was reported as an injury of unknown origin she confirmed it was not. The NHA and DON also confirmed there was no notes in Resident #96's record that mentioned the bruise or how it may have occurred. The NHA indicated the IDT asked the nurse who was working the day they made rounds and say the bruise to do the incident report and the change of condition in the record but the nurse failed to do so. b) Resident #19 A review of the reportable incidents on 06/26/19 at 9:30 a.m. found an incident dated 03/25/19 for Resident #19. Immediate Fax Reporting of Allegations - Nursing Home Program form was reviewed and found the following description of the incident: Resident alleges a CNA was rough with her while providing care. The alleged Perpetrator was listed as unknown. This report was sent to the Nursing Home Program on 03/25/19. A review of the Five Day Follow Up Report completed by Social Worker #96 on 0326/19 contained the following information, On (MONTH) 25. 2019 at approximately 8 AM, resident was brought her breakfast tray by day shift CNA when Resident told her. those two niggers really roughed me up last night, didn't they? All staff who worked the previous day, evening and night shift were interviewed. Three of the eight staff interviewed, stated that resident was extremely combative with care the previous day, which is not uncommon. However, they all denied being roughwith resident while providing care. The social worker identified three (3) staff members as potential perpetrators and noted by them stating they were not rough with the resident. The three (3) staff members were CNA's and should have been reported to the Nurse Aide Program when identified as alleged perpetrators. There was no evidence provided that these three (3) Nurse Aides were reported to the Nursing Home Program. An interview with the Nursing Home Administrator (NHA), the Director of Nursing (DON), and the Registered Nurse Quality Care Specialist (RNQCS) #118 at 3:58 p.m. on 06/26/19 confirmed this allegation as not reported to the Nurse Aide Program when three (3) Nurse Aides were identified as alleged perpetrators. c) Resident #30 A review of the reportable incidents on 06/26/19 at 9:30 a.m. found an incident dated 04/29/19 for Resident #30. The Immediate Fax Reporting of Allegations - Nursing Home Program form was reviewed and found the following description of the incident: Resident heard yelling he's hurting me by another resident a room over (Resident #30) The resident who heard this added there was a male CNA (certified nursing assistant) in her own room when she heard her neighbor yell. The CNA was not in Resident #30's room when she was yelling. The alleged perpetrator was listed as unknown. This report was sent to the Nursing Home Program on 04/24/19. A review of the Adult Protective Service Mandatory Reporting form found the following written by Social Worker #49, Resident heard yelling he's hurting me, he's hurting me This as heard by a resident in a room next door. The only male CNA working as seen in the residents room who heard it while it was being yelled. Potential CNA Suspended. Social Worker #49 identified Nurse Aide #132 as a potential perpetrator because he was the only male nurse aide working. However he did not report this allegation to the Nursing Aide Program as required when the Alleged Perpetrator is a Nurse Aide. An interview with the NH, the DON, and the RNQCS #118 at 3:58 p.m. on 06/26/19 confirmed this allegation was not reported to the Nurse Aide Program when Nurse Aide #132 was identified as an alleged perpetrator. d) Resident #77 A review of the reportable incidents on 06/26/19 at 9:30 a.m. found an incident dated 05/03/19 for Resident #77. Immediate Fax Reporting of Allegations - Nursing Home Program form was reviewed and found the following description of the incident: Residents granddaughter alleges she came to facility at 5:00 p.m. and found Resident in dried bowel movement. Residents granddaughter alleges she was not checked/changed every 2 hours. The alleged Perpetrator was listed as unknown. This report was sent to the Nursing Home Program on 05/03/19. A review of the Five Day Follow Up Report completed by Social Worker #96 on 05/06/19 contained the following information, .Allegation of neglect was reported and investigation was initiated. Facility CNAs who were assigned to resident the previous day were suspended pending investigation. The social worker identified two (2) staff members as potential perpetrators and noted they were suspended pending investigation. However they were not reported to the Nurse Aide Program and required when the alleged perpetrator is Nurse Aide. An interview with the NH, the DON, and the RNQCS #118 at 3:58 p.m. on 06/26/19 confirmed this allegation as not reported to the Nurse Aide Program when two (2) nurse aides were identified as alleged perpetrators. e) Resident #12 A review of the reportable incidents on 06/26/19 at 9:30 a.m. found an incident dated 05/01/19 for Resident #12. Immediate Fax Reporting of Allegations - Nursing Home Program form was reviewed and found the following description of the incident: Alleged resident waited an extended period of time to be changed . The alleged Perpetrator was listed as unknown. This report was sent to the Nursing Home Program on 05/01/19. A review of the Five Day Follow Up Report completed by Social Worker #49 on 05/06/19 contained the following information, . During the evening of (MONTH) 30th nursing staff responded to Resident #12's call light and helped him sit upright in his chair and then returned later with assistance to help Resident #12 get into bed. Then the nurse went to get someone to change Resident #12 and that is when Resident #12 had to wait SW spoke with NA #14 who was the CNA assigned to Resident #12 during the 3 pm to 11 pm shift on (MONTH) 30, 2019. The social worker identified NA #14 as the alleged perpetrator when he narrowed down who was assigned to care for him when the alleged neglect took place. He took a statement from NA #14 further indicating she was the alleged perpetrator. However SW #49 failed to report NA #14 to the Nurse Aide Program as required when a Nurse Aide is identified as the alleged perpetrator. An interview with the NH, the DON, and the RNQCS #118 at 3:58 p.m. on 06/26/19 confirmed this allegation was not reported to the Nurse Aide Program when NA #14 was identified as the alleged perpetrator. f) Resident #212 A review of the reportable incidents on 06/26/19 at 9:30 a.m. found an incident dated 03/19/19 for Resident #212. Immediate Fax Reporting of Allegations - Nursing Home Program form was reviewed and found the following description of the incident: It was reported a black male and female CNA made derogatory comments to Resident #212 during night shift and that he was left on a bed pan which may have left marks on his bottom. The alleged Perpetrator was listed as unknown. This report was sent to the Nursing Home Program on 3/19/19. A review of the Five Day Follow Up Report completed by Social Worker #49 on 03/21/19 contained the following information, . SW reviewed staffing sheets and NA #132 and NA #22 appear to be the only CNAs who work with Resident #212 that fit his description The social worker identified NA #132 and NA #22 as potential perpetrators by reviewing the staffing sheets. However they were not reported to the Nurse Aide Program as required when the alleged perpetrator are Nurse Aides. An interview with the NH, the DON, and the RNQCS #118 at 3:58 p.m. on 06/26/19 confirmed this allegation was not reported to the Nurse Aide Program when NA #132 and NA #22 were identified as alleged perpetrators. g) Resident #213 A review of the reportable incidents on 06/26/19 at 9:30 a.m. found an incident dated 03/04/19 for Resident #213. Immediate Fax Reporting of Allegations - Nursing Home Program form was reviewed and found the following description of the incident: Resident alleges at 10 am on Saturday (MONTH) 2 it took 2 and 1/2 hours for someone to answer his call light. The alleged Perpetrator was listed as unknown. This report was sent to the Nursing Home Program on 3/04/19. A review of the Five Day Follow Up Report completed by Social Worker # 96 on 03/08/19 contained the following information, . Assigned CNA was interviewed and she confirmed she was in and out of the room various times between 7:00 a.m. and 2:00 p.m. The social worker identified the NA assigned to the resident as the alleged perpetrator when she interviewed her and took her statement. However she was not reported to the Nurse Aide Program as required when the alleged perpetrator is a Nurse Aide. An interview with the NH, the DON, and the RNQCS #118 at 3:58 p.m. on 06/26/19 confirmed this allegation was not reported to the Nurse Aide Program when the assigned NA was identified as the alleged perpetrator. h) Resident #214 A review of the reportable incidents on 06/26/19 at 9:30 a.m. found an incident dated 02/04/19 for Resident #214. Immediate Fax Reporting of Allegations - Nursing Home Program form was reviewed and found the following description of the incident: It was reported this resident was in a soaked brief and that he bed linens were also had urine on them. The alleged Perpetrator was listed as unknown. This report was sent to the Nursing Home Program on 02/04/19. A review of the Five Day Follow Up Report completed by Social Worker #49 on 03/21/19 contained the following information, . NA #5, Certified Nursing Assistant, who worked the night shift from (MONTH) 3rd through (MONTH) 4th till 7:00 a.m. reported she made three rounds to the resident's room during the night to provide care. She reported she changed the resident's brief during the first round. The second round the resident was dry and did not need to be changed. She reported she made the third round at 6:15 a.m. and changed the residents brief and stated that the sheets did not need changed at that time. The social worker identified NA #5 as the alleged perpetrator because was the NA assigned to him when the alleged neglect occurred. However he did not report NA #5 to the Nurse Aide Program as required when the alleged perpetrator is a Nurse Aide. An interview with the NH, the DON, and the RNQCS #118 at 3:58 p.m. on 06/26/19 confirmed this allegation was not reported to the Nurse Aide Program when NA #132 and NA #22 were identified as alleged perpetrators. i) Resident #15 A review of the reportable incidents on 06/26/19 at 9:30 a.m. found an incident dated 11/26/18 for Resident #15. Immediate Fax Reporting of Allegations - Nursing Home Program form was reviewed and found the following description of the incident: Resident alleges he requested to get out of bed, the staff stated they were busy and would come back later and did not. The alleged Perpetrator was listed as unknown. This report was sent to the Nursing Home Program on 11/26/18. A review of the Five Day Follow Up Report completed by Social Worker #96 on 11/29/18 contained the following information, . On Saturday, (MONTH) 24, Resident #15 stated that he asked his female nursing assistant, unsure of her name to get him up after lunch. The Assigned CNA for day shift was NA #133 The social worker identified NA #133 as the alleged perpetrator because she was assigned to the resident on the date and time that the allegation allegedly happened. However SW #96 failed to report NA #133 to the Nurse Aide Program as required when the alleged perpetrator is a nurse aide. An interview with the NH, the DON, and the RNQCS #118 at 3:58 p.m. on 06/26/19 confirmed this allegation was not reported to the Nurse Aide Program when NA #133 was identified as the alleged perpetrator. j) Resident #57 A review of the reportable incidents on 06/26/19 at 9:30 a.m. found an incident dated 11/26/18 for Resident #57. Immediate Fax Reporting of Allegations - Nursing Home Program form was reviewed and found the following description of the incident: Residents daughter alleges resident was left in urine or an extended period of time. The alleged Perpetrator was listed as unknown. This report was sent to the Nursing Home Program on 11/26/18. A review of the Five Day Follow Up Report completed by Social Worker #49 on 03/21/19 contained the following information, . Investigation was completed by social services and nursing departments regarding concern and allegation of neglect. By review of the facility sign in record residents daughter visited the center on Saturday (MONTH) 24 at approximately 4:00 p.m. Assigned day and evening CNAs interviewed. The social worker identified the assigned day shift and evening shift CNAs as the alleged perpetrators and took statements from them. However the facility failed to report them to the Nurse Aide Registry as required when the alleged perpetrator is a nurse aide. An interview with the NH, the DON, and the RNQCS #118 at 3:58 p.m. on 06/26/19 confirmed this allegation was not reported to the Nurse Aide Program when the assigned day shift and evening shift nurse aides were identified as alleged perpetrators. k) Resident 29 During an interview on 06/25/19 at 10:20 AM, Resident #29 (who is nonverbal writes with a pen and tablet) stated, that her neck hurts. She wrote that a Nurse Aide (NA) #41, jerked me out my chair to the bed NA #41 was working on night shift. She wrote that it happened on Monday or Tuesday of last week at about 10:00 PM. She reported this to the Social Worker (SW), she gave a description of the NA #41 and pointed her out to SW. She wrote, that the women the women are still here the next night. She also wrote, that the same NA push her into the door hard and hurt her sore feet and happened at 7:00PM. On 06/26/19 a review of the reportable that was provided revealed; Reportable done on 06/20/19, date of incident was on 06/17/19, this report was completed by Social Worker (SW) #49. -There was no evidence that NA #41 was reported to, Nurse Aide registry -There report had the NA named as unknown, even though he named the NA in his statement. -He did not have any witness statements attached to the report. On a typed sheet of paper read as follows: June 20, 2019 Five-day follow-up report Alleged Perpetrator: Unknown Alleged victim: Named Resident #29 Resident #29 reported that someone caring for her had been mean to her. When asked specifically about this she reported that a tall black woman with blonde hair on top of her head jerked her while providing care. She indicated she was in her wheelchair when this occurred, and it caused her foot to bump the door. When asked she indicated she did not have any injury or marks on her from this. She indicated that this person would give her remote when she was back in the bed. SW interviewed Resident#29's roommate. The roommate stated that she did not see any of this occur. She stated there was a time that night when NA was providing care and Resident #29 was groaning. The curtain was pulled so she did not see what occurred. SW interviewed Licensed Practical Nurse (LPN) #93. She reported she was not aware of Resident #29 being upset about any particular treatment. She explained that Resident #29 often groans or raises her voice when being transferred to bed or toileting care. SW interview NA #41, she was the closest fit to the description though not exact. NA #41 did provide care to Resident #29 on 06/17/19. She reported there were instances it was difficult understanding what Resident #29 was requesting. After asking her numerous times her roommate stated she thought she was requesting her remote. NA #41 stated, that she provided the bed remote. When asked about bumping resident #29's foot into anything that she was aware of nor did she jerk her while in her wheelchair. Resident requested not to have that particular NA provide care for her any more, which will be accommodated. The allegation of abuse/neglect will not be substantiated. On the Adult Protective Services Mandatory Reporting Form Resident #29 has capacity Perpetrator: Unknown Date of incident: 06/17/19 Date this report was completed: 06/19/19 Describe incident: Resident alleged NA bumped her foot into doorway and did not give her bed remote. On the form that was faxed to Office of Health Facilities Licensure and Certification Alleged Victim: Resident #29 's Name was noted Alleged perpetrator: Unknown date of incident: 06/17/19 Brief description of incident: Alleged that facility staff came to room to provide care and bumped the resident's foot into a door frame while turning her in the chair. Also, NA did not give her the bed remote while in bed. On 07/01/19 at 4:55 PM, an interview with SW #49 was asked if had had gather witness statements from all employees that worked that night? He shook his head no (to indicate that he does not have any written statements from any employees), he said, that he just ask the employees and he writes the information in, but no signed or written statements. He was asked about why he did not write in the report that the NA #41 had jerked her out of her chair and hurt her. He said, that she did not tell him that, however the attached statements, that Resident #29 had wrote to him, Tall black women with blonde hair on top, jerked me out of my chair to put me in my bed, she hurt my neck. He was asked if NA #41 was put on leave until the investigation was completed? He said no. He was how did he reach the conclusion the allegation was unsubstantiated. He said, that he called NA#41 and she told him that the allegation was false and that had spoken to the nurse that worked that night and she said, that Resident #29 normally makes a moaning sound when she is moved from the chair to the bed. He was asked if he a written statement about that. He went on to say that her roommate told him that she did not see anything because the curtain was pulled but did hear moan. During an interview on 07/02/19 at 9:12 AM, DoN was informed about this report that Social Worker (SW) #49 had done. It was pointed out that it was not a thorough investigation, he did not report to all State required Agencies and that he reported on the Adult Protective Services Mandatory Reporting Form, Allegations Nursing home Program, but failed to report to the Nurse Aide Registry. He also knew who the Alleged Perpetrator was, but he knew who she was, because Resident # 29 pointed her out to the staff and her description was very clear. He said, that he knew who it was from her description. However, he wrote unknown. She agreed that it was not a complete investigation. She was also shown, that he had copies of her written complaint (she is nonverbal) she had written twice that NA #41,jerked her out of her wheel chair and hurt her neck at 10:00 PM and she hit her sore feet on the door at 7:00PM. She agreed he did not do an appropriate investigation. She stated that will talk to him. On 07/02/19 at 10:30 AM, SW #49 provided a copy of; 1:1 Education Form -Employee: NA #41 -Topic of education: Safe Resident Handling Education: -Employee will follow the Care Plan for the resident's lift statuses -Employee will follow the policy for use of gait belt, sit to stand lift, and the total lift devices. This had the signature of the Manager dated 07/01/19 Employee signature NA #41 dated 07/01/119",2020-09-01
848,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,610,D,0,1,LUON11,"Based on resident interview, record review, staff interview and policy review, the facility failed to thoroughly investigated, report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This had the potential to affect a limited number of people. Resident identifier: #29. Facility census 117. Findings included: a) Resident 29 During an interview on 06/25/19 at 10:20 AM, Resident #29 (who is nonverbal writes with a pen and tablet) stated, that her neck hurts. She wrote that a Nurse Aide (NA) #41, jerked me out my chair to the bed NA #41 was working on night shift. She wrote that it happened on Monday or Tuesday of last week at about 10:00 PM. She reported this to the Social Worker (SW), she gave a description of the NA #41 and pointed her out to SW. She wrote, that the women the women are still here the next night. She also wrote, that the same NA push her into the door hard and hurt her sore feet and happened at 7:00PM. On 06/26/19 a review of the reportable that was provided revealed; Reportable done on 06/20/19, date of incident was on 06/17/19, this report was completed by Social Worker (SW) #49. -There was no evidence that NA #41 was reported to, Nurse Aide registry -There report had the NA named as unknown, even though he named the NA in his statement. -He did not have any witness statements attached to the report. On a typed sheet of paper read as follows: June 20, 2019 Five-day follow-up report Alleged Perpetrator: Unknown Alleged victim: Named Resident #29 Resident #29 reported that someone caring for her had been mean to her. When asked specifically about this she reported that a tall black woman with blonde hair on top of her head jerked her while providing care. She indicated she was in her wheelchair when this occurred, and it caused her foot to bump the door. When asked she indicated she did not have any injury or marks on her from this. She indicated that this person would give her remote when she was back in the bed. SW interviewed Resident#29's roommate. The roommate stated that she did not see any of this occur. She stated there was a time that night when NA was providing care and Resident #29 was groaning. The curtain was pulled so she did not see what occurred. SW interviewed Licensed Practical Nurse (LPN) #93. She reported she was not aware of Resident #29 being upset about any particular treatment. She explained that Resident #29 often groans or raises her voice when being transferred to bed or toileting care. SW interview NA #41, she was the closest fit to the description though not exact. NA #41 did provide care to Resident #29 on 06/17/19. She reported there were instances it was difficult understanding what Resident #29 was requesting. After asking her numerous times her roommate stated she thought she was requesting her remote. NA #41 stated, that she provided the bed remote. When asked about bumping resident #29's foot into anything that she was aware of nor did she jerk her while in her wheelchair. Resident requested not to have that particular NA provide care for her any more, which will be accommodated. The allegation of abuse/neglect will not be substantiated. On the Adult Protective Services Mandatory Reporting Form Resident #29 has capacity Perpetrator: Unknown Date of incident: 06/17/19 Date this report was completed: 06/19/19 Describe incident: Resident alleged NA bumped her foot into doorway and did not give her bed remote. On the form that was faxed to Office of Health Facilities Licensure and Certification Alleged Victim: Resident #29 's Name was noted Alleged perpetrator: Unknown date of incident: 06/17/19 Brief description of incident: Alleged that facility staff came to room to provide care and bumped the resident's foot into a door frame while turning her in the chair. Also, NA did not give her the bed remote while in bed. On 07/01/19 at 4:55 PM, an interview with SW #49 was asked if had had gather witness statements from all employees that worked that night? He shook his head no (to indicate that he does not have any written statements from any employees), he said, that he just ask the employees and he writes the information in, but no signed or written statements. He was asked about why he did not write in the report that the NA #41 had jerked her out of her chair and hurt her. He said, that she did not tell him that, however the attached statements, that Resident #29 had wrote to him, Tall black women with blonde hair on top, jerked me out of my chair to put me in my bed, she hurt my neck. He was asked if NA #41 was put on leave until the investigation was completed? He said no. He was how did he reach the conclusion the allegation was unsubstantiated. He said, that he called NA#41 and she told him that the allegation was false and that had spoken to the nurse that worked that night and she said, that Resident #29 normally makes a moaning sound when she is moved from the chair to the bed. He was asked if he a written statement about that. He went on to say that her roommate told him that she did not see anything because the curtain was pulled but did hear moan. During an interview on 07/02/19 at 9:12 AM, DoN was informed about this report that Social Worker (SW) #49 had done. It was pointed out that it was not a thorough investigation, he did not report to all State required Agencies and that he reported on the Adult Protective Services Mandatory Reporting Form, Allegations Nursing home Program, but failed to report to the Nurse Aide Registry. He also knew who the Alleged Perpetrator was, but he knew who she was, because Resident # 29 pointed her out to the staff and her description was very clear. He said, that he knew who it was from her description. However, he wrote unknown. She agreed that it was not a complete investigation. She was also shown, that he had copies of her written complaint (she is nonverbal) she had written twice that NA #41,jerked her out of her wheel chair and hurt her neck at 10:00 PM and she hit her sore feet on the door at 7:00PM. She agreed he did not do an appropriate investigation. She stated that will talk to him. On 07/02/19 at 10:30 AM, SW #49 provided a copy of; 1:1 Education Form -Employee: NA #41 -Topic of education: Safe Resident Handling Education: -Employee will follow the Care Plan for the resident's lift statuses -Employee will follow the policy for use of gait belt, sit to stand lift, and the total lift devices. This had the signature of the Manager dated 07/01/19 Employee signature NA #41 dated 07/01/119 07/01/19 04:55 PM He does not have any written statements from any employees, said, that he just ask the employees and he writes the information in, but no signed or written statements. He was asked about why he did not write in the report that the NA #41 had jerked her and hurt her. He said, that she did not tell him that, however attached to his He was asked what during his investigation asked him for the schedule for (MONTH) for the NA 06/25/19 10:20 AM neck hurts when she jerks me out my chair and bed NA on night shift on Tuesday and Wednesday last week she reported to ss she showed her the women the women is still here she rush her into the door hard hurt my sore feet she wrote I want to leave this place. 07/02/19 09:12 AM DoN was informed about this report that Social Worker (SW) #49 not doing a thorough investigation, not reporting to all State required Agencies and that he reported on the Adult Protective Services Mandatory Reporting Form, Allegations Nursing home Program, but failed to report to the Nurse Aide Registry. He also knew who the Alleged Perpetrator was, but he knew who she was, because Resident # 29 pointed her out to the staff and her description was very clear. He said, that he knew who it was from her description. However he wrote unknown. She agreed that it was not a complete investigation. She was also shown, that he had copies of her written complaint (she is nonverbal) she had wrote twice that NA #41,jerked her out of her wheel chair and hurt her neck at 10:00 PM and she hit her sore feet on the door at 7:00PM. She agreed he did not do a very good job on this. Reportable done on 06/20/19 by Social Worker 49 Resident # 29 reported that a NA was a tall black women with blonde hair",2020-09-01
849,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,622,D,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide documentation to the receiving hospital to ensure a safe transfer for Resident #98. This was true for one of eight residents reviewed for the care area of hospitalization . Resident identifier: #98. Facility census: 117. Findings included: a) Resident #98 On 06/26/19 at 2:35 PM, a closed record review of Resident #98's medical chart revealed the Resident had been transferred to the hospital on [DATE]. The facility failed to ensure the necessary Resident information was documented and included in the transfer of the Resident to the receiving hospital. At 2:40 PM on 06/26/19, the Director of Nursing (DON) confirmed, by interview, the hospital discharge forms for the Resident on the transfer date of 06/18/19, .were not given.",2020-09-01
850,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,623,E,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, facility failed to notify the resident and the resident's representative(s) of the transfer and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. This was true for eight (8) of eight (8) residents sampled for the care area of hospitalization . Resident identifiers: #111, #78, #93, #98, #80, #6, #101 and #38. Facility census: 117. Findings included: a) Resident #111 Review of Resident #111's medical records found this resident was admitted to the facility on [DATE] at 6:39 pm, from an acute care facility with [DIAGNOSES REDACTED]. Noted to have impairment of right upper extremity and weakness in the right arm and both legs. Resident #111's experienced a fall on 02/03/19 at 3:30 pm. Resident's progress note states, Resident was being changed by nurse aide at 3:30 pm. Resident was rolling to the right hand side of the bed when the resident rolled herself from the bed to the floor, the bed was raised to waist height as the aide was performing care on the resident. Post fall the resident c/o (complained of) severe left knee and left rib pain. This nurse contacted the on-call physician who gave orders to have resident sent out to the emergency room to be evaluated for potential fractures. Nurse aide who was performing care will complete a statement regarding the incident. Bruise noted on left knee and left cheek. Review of the Notice of Transfer or discharge found the form was incomplete except Resident's name and date. No indication this was provided to the resident and/or patient's representative. Bedhold Notice of Policy and Authorization was blank of signature. Interview with the Director of Nursing (DON) on 07/01/19 at 1:10 pm. Resident #111's medical records were reviewed by the DON. She confirmed the notice of transfer and bed hold was both incomplete. b) Resident #78 Review of Resident #78's medical records found the resident was admitted to the facility on [DATE]. Transferred to the hospital on [DATE] after experiencing two (2) falls. Review of the Notice of Transfer or discharge found the form was incomplete except Resident's name and date. No indication this was provided to the resident and/or patient's representative. Bedhold Notice of Policy and Authorization was blank of signature. Interview with the Director of Nursing (DON) on 07/01/19 at 1:10 pm. Resident #111's medical records were reviewed by the DON. She confirmed the notice of transfer and bed hold was both incomplete. c) Resident #93 Review of Resident #93's medical records found the resident was admitted to the facility on [DATE]. Transferred to the hospital on [DATE]. Review of the Notice of Transfer or discharge found the form was incomplete except Resident's name and date. No indication this was provided to the resident and/or patient's representative. Bedhold Notice of Policy and Authorization was blank of signature. Interview with the Director of Nursing (DON) on 07/01/19 at 1:10 pm. Resident #111's medical records were reviewed by the DON. She confirmed the notice of transfer and bed hold was both incomplete. d) Resident #38 Record review on 06/26/19 at 3:37 PM, found the resident was discharged to the hospital on [DATE] for a severely extended abdomen. The resident returned to the facility on [DATE]. i) interviews with staff regarding notification of the Ombudsman for the transfers/discharges of Resident's #111, #78, #93, #98, #80, #6, #101, and #38. At 8:57 AM on 06/27/19, the Director of Nursing (DON) and the administrator were interviewed. The administrator said the social workers notify the ombudsman of all discharges from the facility. She said a list of discharged residents is sent to the ombudsman at the end of each month. At 2:15 PM on 7/1/19, Social worker (SW) #96 said she doesn't notify the Ombudsman about resident discharges each month, The medical record clerk does that. At 2:20 PM, the medical record clerk, (MRC) #62 said she was not longer sending the information to the Ombudsman. She said, I guess maybe I should, but the last time I sent any information to the Ombudsman was in (MONTH) (YEAR). MRC #62 could not provide evidence the facility was notifying the ombudsman about the discharges of Resident's #111, #78, #93, #98, #80, #6, #101, and #38. On 07/01/19 at 2:27 PM, the director of nursing (DON) said she was unable to find any evidence to confirm the Ombudsman was notified of any discharges from the facility. The regulations require, Notice before transfer. Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman . e) Resident #101 A review of Resident #101's medical record on 06/25/19 at 9:29 a.m. found the resident was discharged to the hospital on [DATE] and readmitted to the faiclity on 04/26/19. At 9:45 a.m. on 07/01/19 the Director of Nursing was asked to provide the information sent with the resident to the hospital she provided the eInteract Transfer Form, a copy of the bed hold policy and the physician orders [REDACTED]. The facility was unable to provide evidence that this information was sent to the Ombudsman as required. f) Resident #80 Review of records found Resident #80 was sent out to a local hospital on [DATE] and returned on 03/04/19. For a change in mental status. On 07/01/19 at 1:03 PM, Director of Nursing (DoN) was asked for a bed hold for this resident. She stated, that the bed hold was incomplete and not done. She also stated, that the ombudsman was not notified. g) Resident #6 Review of medical records revealed that, Resident #6 was sent out of the facility due [MEDICAL CONDITION], on 3/15/19 returned on 03/19/19. On 07/01/19 at 1:03 PM, Director of Nursing (DoN) stated that they did not complete a bed hold. She also stated, that the ombudsman was not notified. h) Resident #98 During an interview on 06/26/19 at 2:40 PM, the Director of Nursing (DON) confirmed the Ombudsman was not notified of the Residents transfer to the hospital on [DATE].",2020-09-01
851,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,625,E,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that all residents received a Bed-hold notice upon transfer and/or discharge from the facility. This was true for five (5) of eight (8) residents reviewed for the care area of hospitalization . Resident identifiers: #80, #6, #111, #78, and #38. Facility census 117. Findings included: a) Resident #80 Review of records found Resident #80 was sent out to a local hospital on [DATE] and returned on 03/04/19. For a change in mental status. On 07/01/19 at 1:03 PM, Director of Nursing (DoN) was asked for a bed hold for this resident. She stated, that the bed hold was incomplete and not done. She also stated, that the ombudsman was not notified. b) Resident #6 Review of medical records revealed that, Resident #6 was sent out of the facility due [MEDICAL CONDITION], on 3/15/19 returned on 03/19/19. On 07/01/19 at 1:03 PM, Director of Nursing (DoN) stated that they did not complete a bed hold. She also stated, that the ombudsman was not notified. c) Resident #38 Record review on 06/26/19 at 3:37 PM, found the resident was discharged to the hospital on [DATE] for a severely extended abdomen. The resident returned to the facility on [DATE]. On 06/27/19 at 8:47 AM, the director of nursing (DON), provided a copy of a bed hold notice with Resident #38's name written on the bed hold. The form noted the resident had 12 days of bed hold. The DON confirmed the bed hold notice was not dated to indicate when it was sent with the resident. In addition, there was no indication the bed hold policy was discussed with the resident or the responsible party within 24 hours of transfer to the hospital. d) Resident #111 Review of Resident #111's medical records found this resident was admitted to the facility on [DATE] at 6:39 pm, from an acute care facility with [DIAGNOSES REDACTED]. Noted to have impairment of right upper extremity and weakness in the right arm and both legs. Resident #111's experienced a fall on 02/03/19 at 3:30 pm. Resident's progress note states, Resident was being changed by nurse aide at 3:30 pm. Resident was rolling to the right hand side of the bed when the resident rolled herself from the bed to the floor, the bed was raised to waist height as the aide was performing care on the resident. Post fall the resident c/o (complained of) severe left knee and left rib pain. This nurse contacted the on-call physician who gave orders to have resident sent out to the emergency room to be evaluated for potential fractures. Nurse aide who was performing care will complete a statement regarding the incident. Bruise noted on left knee and left cheek. Review of the Notice of Transfer or discharge found the form was incomplete except Resident's name and date. No indication this was provided to the resident and/or patient's representative. Bedhold Notice of Policy and Authorization was blank of signature. Interview with the Director of Nursing (DON) on 07/01/19 at 1:10 pm. Resident #111's medical records were reviewed by the DON. She confirmed the notice of transfer and bed hold was both incomplete. e) Resident #78 Review of Resident #78's medical records found the resident was admitted to the facility on [DATE]. Transferred to the hospital on [DATE] after experiencing two (2) falls. Review of the Notice of Transfer or discharge found the form was incomplete except Resident's name and date. No indication this was provided to the resident and/or patient's representative. Bedhold Notice of Policy and Authorization was blank of signature. Interview with the Director of Nursing (DON) on 07/01/19 at 1:10 pm. Resident #111's medical records were reviewed by the DON. She confirmed the notice of transfer and bed hold was both incomplete.",2020-09-01
852,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,636,D,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the care area assessment (CAA) worksheet of the minimum data set (MDS) was completed with current evidence-based information regarding the care area of activities for one (1) of three (3) residents who triggered activities. Resident identifier: #161. Facility census: 117. Findings included: a) Resident #161 Record review at 9:11 AM on 06/27/19, found the resident was admitted to the facility on [DATE]. The resident was discharged from the facility on 05/13/19. Review of the Resident's admission MDS with a reference assessment date of 04/17/19 found the resident triggered the care area of activities. The facility answered-yes, to the question on the CAA worksheet, Will activities-Functional status be address in the care plan? The CAA further indicated if care planning for this problem one of the overall objectives needs to be checked: improvement, slow or minimize decline, avoid complications, maintain current level of functioning, minimize risks, and symptom relief or palliative measure. None of these choices were checked. The CAA required documentation for: Description impact of this problem/need on the resident and your rationale for care plan decision. This was also incomplete. On 06/27/19 at 10:05 AM, the Registered Nurse (RN), (minimum data set coordination), RNMDSC #95 confirmed the CAA worksheet was incomplete.",2020-09-01
853,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,641,E,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, facility failed to ensure the Minimum Data Sets (MDS)s accurately reflected the resident's status. This was true for five (5) of forty-one (41) resident's MDSs reviewed during the Long-Term Survey Process (LTCSP). Resident #113's MDS was inaccurate in the area of prognosis/death in the facility. Residents #91 and #92's MDS was inaccurate in area of nutritional/weight loss status. Residents #103 and #3's MDS was inaccurate in area of medication. Resident's identifiers: #113, #91, #92, #103 and #3. Facility census: 117. Findings included: a) Resident #113 Resident #113 was admitted to the facility on [DATE] from an acute care facility. Resident's [DIAGNOSES REDACTED]. Review of the attending physicians' progress note dated, 03/01/19 at 2:41 pm, states, . Prognosis is terminal, with a predicted survival of less than three (3) months . Review of the admission MDS with an assessment reference date (ARD) of 03/07/19. Review of section J 1400 Prognosis was marked to indicate the resident did not have a condition or chronic disease that may result in a life expectancy of less than six (6) months. Interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 06/27/19 at 11:00 am, confirmed the resident had was terminal and the MDSs with ARD of 03/07/19 inaccurately coded. They both agreed the MDS should have been coded, Life expectancy of less than six (6) months. b) Resident #91 Medical record review for Resident #91, found the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Admission nursing assessment reviewed, no weight and/or height was obtained. Review of the admission MDS with ARD of 06/07/2019 under section K lists the weight as 128. Nutritional care plan for Resident #91 was initiated on 06/07/19 as follows: -- Focus: Resident is a potential nutritional concern related to (r/t) fair po (by mouth) intakes, [DIAGNOSES REDACTED]. -- Goal: No significant weight changes through next review. (MONTH) experience some weight fluctuations based on diuretic ([MEDICATION NAME]) treatment in place. --Interventions: Proheal (protein supplement) as ordered. Honor food preferences within meal plan. Weigh as ordered/needed and alert dietician and physician to any significant loss or gain. Monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain and abnormal labs) and report to food and nutrition/physician as indicated. Monitor intake at all meals, offer alternate choices as needed, alert dietician physician to any decline in intake. Provide diet as ordered Offer snacks. --On 06/08/19, a nutritional assessment for Resident #91, completed by the Registered Dietician (RD) with no weight and/or height recorded. Under nutritional history reads: .No height/weight available at time of assessment Review of Resident #91's weight and vitals summary found resident's height and weight was obtained on 06/11/19 at 6:35 pm. Weight 127.8 and Height 59 inches. Facility's weight and height policy reviewed and found: Patients are weighed upon admission and/or re-admission, then weekly for four (4) weeks and monthly thereafter. Patients height will be measured upon admission, re-admission, and annually and recorded in Point Click care (PCC). Purpose: To obtain baseline weight and identify significant weight change. To determine possible causes of significant weight change. To obtain baseline height. Review of the Resident Assessment Instrument (RAI) found the following steps on assessment and coding instructions on the MDS regarding height and weight: -- Steps for Assessment for K0200A, Height 1. Base height on the most recent height since the most recent admission/entry or reentry. Measure and record height in inches. 2. Measure height consistently over time in accordance with the facility policy and procedure, which should reflect current standards of practice (shoes off, etc.). 3. For subsequent assessments, check the medical record. If the last height recorded was more than one year ago, measure and record the resident's height again. --Steps for Assessment for K0200B, Weight 1. Base weight on the most recent measure in the last 30 days. 2. Measure weight consistently over time in accordance with facility policy and procedure, which should reflect current standards of practice (shoes off, etc.). 3. For subsequent assessments, check the medical record and enter the weight taken within 30 days of the ARD of this assessment. 4. If the last recorded weight was taken more than 30 days prior to the ARD of this assessment or previous weight is not available, weigh the resident again. 5. If the resident's weight was taken more than once during the preceding month, record the most recent weight. Interview on 07/02/19 at 11:10 am, with the Director of Nursing (DON) found the weight entered on Resident #91's admission MDS assessment with the ARD of 06/07/19 was not obtained until four (4) days after the ARD date and should not have been used. She confirmed the resident's height and weight on admission and/or readmission should be obtained within 24 hours of admission/readmission. She also confirmed weights used on the MDS should be obtained prior to the ARD date. c) Resident #92 Medical record review for Resident #92, found the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Admission nursing assessment reviewed, no weight and/or height was obtained. On 06/06/19, a nutritional assessment for Resident #92, completed by the Registered Dietician (RD) with no weight and/or height recorded. Under nutritional history reads: .No height/weight available at time of assessment Nutritional care plan for Resident #92 was initiated on 06/07/19 as follows: --Focus: Resident is a potential nutritional concern related to (r/t) [DIAGNOSES REDACTED]. --Goal: No significant weight changes through next review. -- Interventions: Honor food preferences within meal plan. Weigh as ordered/needed and alert dietician and physician to any significant loss or gain. Monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain and abnormal labs) and report to food and nutrition/physician as indicated. Monitor intake at all meals, offer alternate choices as needed, alert dietician physician to any decline in intake. Provide diet as ordered Offer snacks. Review of Resident #92's admission MDS with ARD of 06/08/2019 under section K lists the weight as 180. Review of Resident #92's weight and vitals summary found resident's height and weight was obtained on 06/12/19 at 1:25 pm. Weight 180.2 and Height 67 inches. Facility's weight and height policy reviewed and found: Patients are weighed upon admission and/or re-admission, then weekly for four (4) weeks and monthly thereafter. Patients height will be measured upon admission, re-admission, and annually and recorded in Point Click care (PCC). Purpose: To obtain baseline weight and identify significant weight change. To determine possible causes of significant weight change. To obtain baseline height. Review of the Resident Assessment Instrument (RAI) found the following steps on assessment and coding instructions on the MDS regarding height and weight: --Steps for Assessment for K0200A, Height 1. Base height on the most recent height since the most recent admission/entry or reentry. Measure and record height in inches. 2. Measure height consistently over time in accordance with the facility policy and procedure, which should reflect current standards of practice (shoes off, etc.). 3. For subsequent assessments, check the medical record. If the last height recorded was more than one year ago, measure and record the resident's height again. --Coding Instructions for K0200A, Height o Record height to the nearest whole inch. o Use mathematical rounding (i.e., if height measurement is [MEDICAL CONDITION] inches or greater, round height upward to the nearest whole inch. If height measurement number is [MEDICAL CONDITION] to [MEDICAL CONDITION] inches, round down to the nearest whole inch). For example, a height of 62.5 inches would be rounded to 63 inches and a height of 62.4 inches would be rounded to 62 inches. --Steps for Assessment for K0200B, Weight 1. Base weight on the most recent measure in the last 30 days. 2. Measure weight consistently over time in accordance with facility policy and procedure, which should reflect current standards of practice (shoes off, etc.). 3. For subsequent assessments, check the medical record and enter the weight taken within 30 days of the ARD of this assessment. 4. If the last recorded weight was taken more than 30 days prior to the ARD of this assessment or previous weight is not available, weigh the resident again. 5. If the resident's weight was taken more than once during the preceding month, record the most recent weight. Interview on 07/02/19 at 11:10 am, with the Director of Nursing (DON) found the weight entered on Resident #92's admission MDS assessment with the ARD of 06/08/19 was not obtained until four (4) days after the ARD date and should not have been used. She confirmed the resident's height and weight on admission and/or readmission should be obtained within 24 hours of admission/readmission. She also confirmed weights used on the MDS should be obtained prior to the ARD date. d) Resident #3 Review of Resident #3's physician's orders [REDACTED]. On 03/06/19, Resident #3 was receiving [MEDICATION NAME] 2 mg at bedtime when the consulting pharmacist recommended a gradual dose reduction (GDR) of the medication. The physician agreed with the pharmacist's recommendation and on 03/12/19 an order was written for [MEDICATION NAME] 1 mg at bedtime. Resident #3 experienced an increase in her depressive symptoms. On 05/13/19, Resident #3's [MEDICATION NAME] was increased to 2 mg at bedtime. Resident #3 continued to experience an increase in her depressive symptoms. On 05/20/19, Resident #3's [MEDICATION NAME] was increased to 5 mg at bedtime. Resident #3's Minimum Data Set (MDS) with Assessment Resident Date 06/18/19, Section N, Item N0410, A, Medications Received, stated the resident received antipsychotic medication seven (7) of the last seven (7) days. Section N, Item N0450, A, Antipsychotic Medication Review, stated the resident had not received antipsychotic since the prior assessment. Due to this response, Item N0450, B, regarding whether a GDR was attempted was not answered. During an interview on 06/26/19 at10:22 AM, the Director of Nursing (DoN) stated Section N, Item N0450, A, was completed incorrectly. She stated this item should have stated Resident #3 had received antipsychotics, and the information regarding the GDR should have been completed. No further information was received before the completion of the survey. e) Resident #103 During the survey, a review of Resident #103's most recent comprehensive Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/10/19 found that Resident #103 had received antipsychotic medications seven (7) out of seven (7) days during the assessment's look-back period. This information was recorded in box N0410 of the MDS. A review of Resident #103's Medication Administration Record [REDACTED]. However, box N0450 of the MDS was coded No - Antipsychotics were not received. During an interview on 07/01/19 at 10:33 AM, the facility's Director of Nursing (DoN) agreed that box N0450 had been coded incorrectly. No further information was provided prior to the end of the survey.",2020-09-01
854,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,655,D,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop and implement a baseline care plan for Resident #111's to include the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must be developed within 48 hours of a resident's admission and include the minimum healthcare information necessary to properly care for a resident including, but not limited to initial goals based on admission orders [REDACTED]. Resident identifier: #111. Facility census: 117. Findings included: a) Resident #111 Review of Resident #111's medical records found this resident was admitted to the facility on [DATE] at 6:39 pm, from an acute care facility with [DIAGNOSES REDACTED]. Noted to have impairment of right upper extremity and weakness in the right arm and both legs. Review of the interim care plan dated 02/03/19 found no directions for assistance required to provide Activities of Daily Living (ADL)s which includes bed mobility, transfers, eating, toileting, dressing, grooming, and bathing. Resident #111's experienced a fall on 02/03/19 at 3:30 pm. Resident's progress note states, Resident was being changed by nurse aide at 3:30 pm. Resident was rolling to the right hand side of the bed when the resident rolled herself from the bed to the floor, the bed was raised to waist height as the aide was performing care on the resident. Post fall the resident c/o (complained of) severe left knee and left rib pain. This nurse contacted the on-call physician who gave orders to have resident sent out to the emergency room to be evaluated for potential fractures. Nurse aide who was performing care will complete a statement regarding the incident. Bruise noted on left knee and left cheek. Review of policy for Falls Management reads: Perform neurological assessment for all unwitnessed falls and witnessed falls with head injury This survey requested the statement from the nurse aide providing care for Resident #111 on 02/03/19 at 3:30 pm and neurological checks. No information was provided. emergency room report status [REDACTED]. No fractures or dislocations noted. Resident #111 was seen and examined by the attending physician on 02/04/19. Progress note states, She reports that yesterday she rolled out of bed onto her face during change and hit her face and knee. She was transferred to (name of hospital) where x-rays were done, and they were negative for fracture. She complains of severe pain around the left side of face Mild bruising and tenderness noted around the left periorbital area Resident was evaluated by physical and occupational therapy on 02/04/19. An assessment dated [DATE] at 1:59 performed by a registered nurse (RN) which indicates the resident requires extensive assistance of two or more persons for bed mobility. Interview with the Director of Nursing (DON) on 07/01/19 at 1:10 pm. Resident #111's medical records were reviewed by the DON. She confirmed the licensed staff had not evaluated and developed a baseline care plan to include the assistance needed for bed mobility and no directions for care was provided to the direct care staff. No further information provided.",2020-09-01
855,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,656,E,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to develop and/or implement each residents care plan. For Resident #161 the facility failed to develop a complete care plan for activities. In addition the facility failed to implement the care plan for a resident with significant weigh loss. For Resident #49 the facility failed to implement the care plan for accident prevention. For Resident #28 the facility failed to develop a care plan detaining how the resident would communicate needs with staff. For Resident #51 the facility did not implement the care plan for nutrition. This was true for four (4) of forty-one (41) residents who's care plans were reviewed. Resident identifiers: #161, #49, #28, and #51. Facility census: 117. a) Resident #161-activities (part 1) Review of the resident's care plan for activities found the following focus/problem: While in the facility, resident states that it is important that she has the opportunity to engage in daily routines that are meaningful relative to their (typed as written) preferences. The goal associated with the problem: Resident will plan and choose to engage in preferred activities. Interventions included: It is important for me to choose my bedtime and I prefer to go to bed whenever I want, I enjoy watching TV, I benefit from being informed of facility happenings. At 8:36 AM on 07/01/19, the activity director (AD # 45 said the resident frequently attended church and music events while at the facility-this was her preferred activities. The care plan was reviewed with AD #45. AD#45 said those activities were not listed on the care plan as activities the resident preferred to attend. Resident #161-nutrition (part 2) Record review at 9:00 AM on 06/26/19 found the Resident was admitted to the facility from the hospital on [DATE]. The resident was discharged from the facility on 05/13/19. Review of the residents care plan found the following problem: Resident is a nutritional concern poor intake with significant weight loss over 1 month, revised on 5/14/19. The goal associated with the problem: Resident will consume 50% of at least all meals through next review. Approaches included: Monitor intake at all meals, offer alternative choices as needed, alert dietician and physician to any decline in intake. The following weights were recorded in the facility's electronic medical record: --05/07/2019 10:37 175.0 pounds (Lbs.) --05/01/2019 15:07 174.8 Lbs --04/24/2019 17:14 186.0 Lbs --04/18/2019 13:14 186.0 Lbs --04/10/2019 16:47 191.2 Lbs The resident had a 8.47% from 04/10/19 to 05/07/19. The resident's admission minimum data set (MDS) with an assessment reference date (ARD) of 04/17/19 coded the resident as requiring extensive assistance of 1 staff member for eating. At 10:00 AM on 6/26/19, the administrator confirmed the facility does not document the daily percentage of fluid consumed by any resident. Review of the activities of daily living (ADL) record found the following days when no meal percentages were documented for the month of April, 2019: --04/12/19 -no documentation for dinner --04/14/19 no documentation for breakfast, lunch or dinner --04/15/19 no documentation for dinner --04/18/19 no documentation for dinner --04/20/19, no documentation for breakfast, lunch or dinner --04/21/19 no documentation for dinner --04/22/19 no documentation for breakfast, lunch or dinner --04/23/19 no documentation for dinner --04/24/19 no documentation for dinner --04/26/19 no documentation for dinner --04/27/19 no documentation for dinner --04/28/19 no documentation for dinner --04/29/19 no documentation for breakfast, lunch or dinner --04/30/19 no documentation for breakfast or lunch. May 2019 --05/03/19 no documentation for dinner --05/04/19 no documentation for breakfast, lunch or dinner --05/05/19 no documentation for breakfast, lunch or dinner --05/06/19 no documentation for dinner --05/09/19 no documentation for breakfast or lunch --05/10/19 no documentation for breakfast, lunch or dinner --05/11/19 no documentation for breakfast, lunch or dinner --05/12/19 no documentation for breakfast, lunch or dinner The resident discharged to home on the morning of 5/13/19. On 07/01/19 at 2:05 PM, the dietary manager (DM) and the Regional dietary manager said they couldn't comment on why the facility was not monitoring the amount of meals consumed for a resident who was loosing weight. The DM said he wasn't employed at the facility at the time. The DM said he would call the registered dietician (RD). The care plan was reviewed with the DM. The DM confirmed the facility could not be following the care plan to monitor intake at meals if the percentage of the meal eaten was not being recorded. He further confirmed it would not be known if the resident needed a substitute meal if no one knows if the regular meal is being consumed. During a telephone call at approximately 3:00 PM on 07/01/19, the RD said she was aware the meal percentages where not being documented and she believed she talked to the MDS coordinator about the problem. The RD said she was concerned as it is important to know if the resident is eating the meals or refusing the meals. . b) Resident #51 A review of the ADL flow sheets for Resident #51's meal intakes at 3:22 p.m. on 07/01/19 from 05/01/19 through current found Resident #51 only had meal percentages recorded for only 80 of the 183 meals. Further review of the record found the following care plan related to his nutritional status: Focus Statement: Resident is a nutritional concern related to significant weight loss X 6 months and [DIAGNOSES REDACTED]. that may impact nutritional status. Goal Statement: No signficant weight changes through next review. Goal for Weight Maintenance. Interventions include: Monitor intake at all meals, offer alternate choices as needed, alert dietician and physician to any decline in intake. An interview with the Director of Nursing (DON) at 3:50 p.m. at 07/01/19 confirmed the residents meal percentages had not been consistently documented and the nutritional care plan had not been implemented. . c) Resident #49 Review of Residents care plan revealed focus area for fall preventions that included an intervention initiated on 03/25/19 for non-skid strips to be implemented on the right side of Resident's bed. On 07/01/19 at 10:00 AM observation of Resident's room (room [ROOM NUMBER]B) revealed non-skid strips were not present or in use as a fall prevention. At 10:17 AM on 07/01/19, RN #28 verified non-skid strips were not in use in the Resident's room (room [ROOM NUMBER]B), as indicated for fall precautions. RN stated, I bet they forgot to put those (non-skid strips) down after they moved the Resident from the other room. d) Resident #28 On 6/25/19 at 2:30 PM, Resident mother/medical power of attorney stated the Resident speaks very little, if at all. The Resident's mother stated the Resident communicates with her by texting from his cell phone, and he will often send her pictures of the menu to let her know if it is something he likes, so she can bring him something to eat if need be. The Resident's mother stated this is something that seems to work well for him to communicate effectively, and he has adapted to using this to communicate with staff by typing wants and needs on cell phone and showing it to staff. 06/26/19 at 2:14 PM Charge Nurse LPN #51 stated they communicate with Resident #28 by him typing on his phone and then showing it to staff. LPN #51 said He (Resident #28) has mentally of 3 year old, but he can text and show us what he wants. At 3:20 PM on 6/26/19 during an interview Certified Nursing Assistant (CNA) #38 stated, (Resident #28's first name) communicates through his phone, he types his wants and needs and shows to us. He (Resident #28) does not say yes or no just giggles, does not speak. On 6/27/19 at 10:50 AM CNA # 86 stated, Resident #28 first name) talks to us by typing on his cell phone and shows us. We (facility staff) use simple one word prompts, like drink and he responds well to that. Review of Resident's Care Plan on 06/27/19 at 11:00 AM revealed focus area of impaired communication as evidenced by [MEDICAL CONDITION]. The goal for Resident was for the Resident's wants and needs will be anticipated and met. Interventions listed on the Care Plan included: --Speech therapy per MD orders. --Speak in normal tone voice clearly and slowly. --Repeat answers to verify that what you understood is correct. --Provide emotional support and encouragement. --Allow sufficient time for the resident to process and respond. --Allow time for resident to express needs. --Place call bell within reach at all times. --An appropriate intervention for the Resident's current form of communication (via route of typing and texting on cell phone) was not included within the Care Plan. During an interview on 07/20/19 at 9:00 AM Social Service specialist #96 verified that the Resident's primary form of communication was by texting and typing his wants and needs on his cell phone. I agree that should have been on the care plan, it is important to let staff know how that is how he communicates. I will go add that right now.",2020-09-01
856,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,657,E,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and record review, the facility failed to ensure all residents were invited to participate in their interdisciplinary care plan meetings. Additionally, Resident #23 and Resident #28's care plans were not revised. These deficient practices were found for seven (7) of 41 sampled residents. Resident identifiers: #24, #104, #23, #80, #6, #49, #28. Facility census: 117. Findings included: a) Resident #24 On 06/25/19 at 12:13 PM, Resident #24 expressed that she wanted to go to her care plan meetings, but that she was not invited to participate. On 06/26/19 at 8:43 AM, the facility's Administrator was asked to provide Resident #24's care plan meeting notes and invitations to care plan meetings for the past year. Upon receipt of the requested information at 9:38 AM, it was noted that Resident #24's care plan meetings during the past year had been held on the following dates: 06/14/18, 08/02/18, and 10/25/18. Additionally, the only invitations to the care plan meetings provided by the facility for review were directed toward Resident #24's responsible party. Each invitation encouraged the responsible party to attend the meeting to discuss resident progress and current care needs of their loved one. Upon further review during the survey, the care plan meeting note for 06/14/18 stated, resident was invited; did not attend. The care plan meeting note for 08/02/18 stated, resident was invited; did not attend. The care plan meeting note for 10/25/18 stated, resident was invited; she did not wish to attend. On 06/26/19 at 10:53 AM, care plan meeting invitations to Resident #24 (not her responsible party) were requested from the facility's Administrator, Director of Nursing (DoN), and Clinical Quality Specialist (CQS) #118. They stated that they would contact the facility's social workers, who were both on vacation during the survey, to see if they could provide additional information about the process for inviting residents to their care plan meetings. On 06/26/19 at 2:50 PM, CQS #118 stated that she had spoken with one of the facility's social workers who had told her that only residents determined to have decision-making capacity received an invitation to their care plan meetings. Upon considering the regulation's requirement that all residents be invited to participate in their care plan conferences, regardless of capacity, CQS #118 stated that this was something the facility needed to look into. No further information was provided prior to the end of the survey. b) Resident #104 On 06/25/19 at 10:55 AM, Resident #104 said that she hadn't been invited to her care plan meetings. On 06/26/19 at 8:43 AM, the facility's Administrator was asked to provide Resident #104's care plan meeting notes and invitations to care plan meetings for the past year. Upon receipt of the requested information at 9:38 AM, it was noted that Resident #104's care plan meetings during the past year had been held on the following dates: 07/19/18, 09/27/18, 12/27/18, and 03/28/19. Additionally, the only invitations to the care plan meetings provided by the facility for review were directed toward Resident #104's responsible party. Each invitation encouraged the responsible party to attend the meeting to discuss resident progress and current care needs of their loved one. Upon further review during the survey, the care plan meeting note for 07/19/18 stated, resident and daughter invited; did not attend. The care plan meeting note for 09/27/18 stated, resident and daughter invited; did not attend. The care plan meeting note for 12/27/18 stated, resident and family invited; did not attend. The care plan meeting note for 03/28/19 stated, resident and family invited; did not attend. On 06/26/19 at 10:53 AM, care plan meeting invitations to Resident #104 (not her responsible party or family) were requested from the facility's Administrator, Director of Nursing (DoN), and Clinical Quality Specialist (CQS) #118. They stated that they would contact the facility's social workers, who were both on vacation during the survey, to see if they could provide additional information about the process for inviting residents to their care plan meetings. On 06/26/19 at 2:50 PM, CQS #118 stated that she had spoken with one of the facility's social workers who had told her that only residents determined to have decision-making capacity received an invitation to their care plan meetings. Upon considering the regulation's requirement that all residents be invited to participate in their care plan conferences, regardless of capacity, CQS #118 stated that this was something the facility needed to look into. No further information was provided prior to the end of the survey. c) Resident #23 On 06/24/19 at 1:42 PM, Resident #23 stated that she had lost approximately 20 pounds awhile back. She stated that her weight had dropped from 98 pounds to the 70s. A review of Resident #23's physician's orders [REDACTED]. A review of Resident #23's nutrition care plan revealed the following intervention, created on 07/11/18, which had never been revised: Monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to nutrition/physician as indicated. During an interview on 06/26/19 at 3:10 PM, the facility's DoN and CQS #118 agreed that the above care plan intervention was not appropriate for Resident #23 and needed revision because weight changes and abnormal labs could not be evaluated since Resident #23 had been ordered to have no weights or labs since 09/26/18. No further information was provided prior to the end of the survey. d) Resident #80 During an interview on 06/25/19 at 9:21 AM, Resident #80 said, that she had never been to a care plan meeting and does not know what it is. Resident #80 has capacity. She was readmitted on [DATE]. She states, that she went home for only a few hours a came back, because she was unable to care for herself. Prior to that date she was admitted on [DATE]. A nursing note dated 02/07/19, Type: Care Plan Meeting 1. Attendance: Social Worker # 49, Social Worker #96, Unit Manager #87, an employee that no longer works at this facility, a Nurse Aide that is longer an employee and Occupational therapist that also is no longer employed at this facility. This did no list that resident. At the bottom of the printed note it was signed by all that attended the Care Plan meeting. A nurse note dated 04/15/19 that was a Late Entry note, listed for attendees: Patient (No name), Social Services (No name), Nurse (No name), Unit Manager (no name) and Rehab (No names). Also, there was no signatures on the bottom of the page. During an interview on 06/26/19 at 10:53 AM, Administrator and Director of Nursing stated, that they would look for more information. There was not a letter to notify the resident about the date and time of the Care Plan Meeting. No additional information was provided before exit. e) Resident #6 During an interview on 06/25/19 at 11:36 AM, Resident #6 stated, that he had one when he wanted to leave a while back, but not since then. Resident #6 has capacity. He stated, that if he could go to one, he would ask about having a power wheel chair again. Nursing note: Care Plan Meeting, dated: 04/04/19 on question 2. asked if resident or family in attendance: None present. This note did not say if he was in invited or not. On 07/01/19 at 10:45 AM, Director of Nursing agreed it is unclear if the resident was invited or not. There was a copy of a letter, but again it was unclear if it was given to the resident or his family. f) Resident #49 During initial screening process on 06/24/19 at 10:57, Resident stated she had never been invited to attend a Care Plan meeting and had never been to a Care Plan since she had been at the facility. Review of care plan notes provided by the Administrator revealed the family and Resident did not attend care plan meetings held on the following dates: 11/15/18: Family/resident were not in attendance, resident and family was invited but did not attend. 08/09/18: Family/resident were not attendance. The facility was unable to provide any documentation of invitations sent to the Resident for attendance of Care Plan Meetings. At 2:50 PM on 06/26/19, Clinical Quality Specialist Registered Nurse (RN) #118 stated, I spoke with the social services department and said they do not invite the resident to care plan meeting unless they have capacity. Review of Resident's Physician Determination of Capacity form indicated Resident #49 was certified by the Physician not to have capacity on 02/11/18. Review of the facility's policy titled Person Centered Care Plan revealed in section eight (8) that the facility has a responsibility to assist residents to participate in Care Plan meetings by extending invitations to the resident sent in advance, and facilitating the inclusion of the resident/resident representative to attend. g) Resident #28 On 6/25/19 at 2:30 PM during an interview Resident's mother/medical power of attorney stated the Resident speaks very little, if at all. The Resident's mother stated the Resident communicates with her by texting from his cell phone, and he will often send her pictures of the menu to let her know if it is something he likes, so she can bring him something to eat if need be. The Resident's mother stated this is something that seems to work well for him to communicate effectively, and he has adapted to using this to communicate with staff by typing wants and needs on cell phone and showing it to staff. The Resident's mother also stated she had not been invited to care plan meeting since the Resident was admitted in February. Review of records on 06/27/19 at 11:00 AM indicate an admission date of [DATE] for the Resident with only one Care Plan meeting held thus far on 03/07/19 with the mother in attendance. The last review date listed on the Care Plan was 04/23/19. On 06/26/19 at 2:14 PM Charge Nurse LPN #51 stated they communicate with Resident #28 by him typing on his phone and then showing it to staff. LPN #51 said He (Resident #28) has mentally of 3-year-old, but he can text and show us what he wants. At 3:20 PM on 6/26/19 during an interview Certified Nursing Assistant (CNA) #38 stated, (Resident #28's first name) communicates through his phone, he types his wants and needs and shows to us. He (Resident #28) does not say yes or no just giggles, does not speak. On 6/27/19 at 10:50 AM CNA # 86 stated, (Resident #28 first name) talks to us by typing messages on his cell phone and then shows us. We (facility staff) use simple one-word prompts, like drink and he responds well to that. Review of Resident's Care Plan on 06/27/19 at 11:00 AM revealed focus area of impaired communication as evidenced by [MEDICAL CONDITION]. The goal for Resident was for the Resident's wants and needs will be anticipated and met. Interventions listed on the Care Plan included: --Speech therapy per MD orders. --Speak in normal tone voice clearly and slowly. --Repeat answers to verify that what you understood is correct. --Provide emotional support and encouragement. --Allow sufficient time for the resident to process and respond. --Allow time for resident to express needs. --Place call bell within reach at all times. An appropriate intervention for the Resident's current form of communication (via route of typing and texting messages on his cell phone) was not included within the Care Plan. During an interview on 07/20/19 at 9:00 AM Social Service specialist #96 verified that the Resident's primary form of communication was by texting and typing out his wants and needs on his cell phone. I agree that should have been on the care plan, it is important to let staff know how that is how he communicates. I will go add that right now.",2020-09-01
857,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,660,D,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure Resident #102's comprehensive care plan included discharge planning. This was true for one (1) of four (4) residents reviewed for the care area of discharge. Resident identifier: #102. Facility census: 117. Findings included: a) Resident #102 Review of Resident #102's medical records revealed she was admitted to the facility on [DATE] and transferred to another long-term care facility on 06/19/19. Resident #102's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 06/12/19, Section Q, Participation in Assessment and Goal Setting, stated the resident expected to be discharged to another facility. Review of Resident #102's Comprehensive Care Plan revealed a care plan focus had not been developed regarding the resident's desire to be transferred to another long-term care facility. During an interview on 06/26/19 at 12:48 PM, the Director of Nursing agreed a care plan focus had not been developed regarding Resident #102's discharge plans. No further information was provided through the completion of the survey.",2020-09-01
858,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,677,E,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, policy review and staff interview, the facility failed to ensure all dependent care residents received the necessary care and services to maintain good nutrition, grooming, and personal and oral hygiene. Resident #91, #78, #162, #211, #161, #163, #53, #92, #93, #95, #38, #1, #68, #101, #51, #70, #94, #49, #106, #26, #56, #97, #58, #59, #69, #27, #86, #46, #99, #25, #90, #76, #89, #8 and #16 did not receive showers according to resident's preference and/or shower schedule . This practice has the potential to affect all resident's residing in the facility. This deficient practice was true for thirty-even (37) of forty-one (41) sampled residents. Resident identifiers: #111, #91, #78, #162, #211, #163, #53, #92, #93, #95, #161, #38, #1, #68, #101, #51, #70, #94, #49, #106, #26, #56, #97, #58, #59, #69, #27, #86, #46, #99, #25, #90, #76, #89, #8, #16, and #23. Facility census: 117. Findings included: a) Resident #91 Review of Resident #91's medical records found she was admitted to the facility on [DATE]. Her shower schedule for room [ROOM NUMBER]-A was for every Wednesday and Saturday. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received two (2) of the nine (9) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive showers on the scheduled dates in (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. b) Resident #78 Review of Resident #78's medical records found the resident was admitted to the facility on [DATE]. Shower schedule for room [ROOM NUMBER]-B was for every Tuesday and Friday. Review of the (MONTH) and (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received one (1) of the eight (8) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive showers on the scheduled dates in (MONTH) and (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. c) Resident #162 Review of Resident #162's medical records found the resident was admitted to the facility on [DATE]. Shower schedule for room [ROOM NUMBER]-A was for every Tuesday and Friday. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received none (0) of the four (4) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the Resident did not receive showers on the scheduled dates in (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. d) Resident #211 Review of Resident #211's medical records found the resident was admitted to the facility on [DATE]. Shower schedule for room [ROOM NUMBER]-B was for every Tuesday and Friday. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received none (0) of the four (4) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive showers on the scheduled dates in (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. e) Resident #163 Review of Resident #163's medical records found she was admitted to the facility on [DATE]. Her shower schedule for room [ROOM NUMBER]-B was for every Monday and Thursday. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received none (0) of the two (2) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive showers on the scheduled dates in (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. f) Resident #53 Review of Resident #53's medical records found she was admitted to the facility on [DATE]. Her shower schedule for room [ROOM NUMBER]-B was for every Monday and Thursday. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received none (0) of the eight (8) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive showers on the scheduled dates in (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. g) Resident #92 Review of Resident #92's medical records found she was admitted to the facility on [DATE]. Her shower schedule for room [ROOM NUMBER]-A was for every Tuesday and Friday. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received one (1) of the eight (8) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive showers on the scheduled dates in (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. h) Resident #93 Review of Resident #93's medical records found the resident was admitted to the facility on [DATE]. Shower schedule for room [ROOM NUMBER]-B was for every Monday and Thursday. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received one (1) of the eight (8) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive showers on the scheduled dates in (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. i) Resident #95 Review of Resident #95's medical records found the resident was admitted to the facility on [DATE]. Shower schedule for room [ROOM NUMBER]-B was for every Monday and Thursday. On 06/20/19, the resident was transferred to room [ROOM NUMBER]-B and the shower schedule remained on the same days. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received one (1) of the seven (7) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive showers on the scheduled dates in (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. k) Resident #161 Review of the resident's closed medical record found she was admitted to the facility on [DATE] and discharged from the facility on 05/13/19. At 06/26/19 at 3:24 PM, the Residents activities of daily living (ADL) records for (MONTH) and (MONTH) 2019, were reviewed with the director of nursing, (DON) and Registered nurse (RN) #118 the corporate clinical quality specialist. The DON said the Resident's showers days were every Wednesday and Saturday for a total of two showers per week. The resident should have received 5 showers in (MONTH) and 4 showers in May, for a total of 9 showers. The resident received only 3 showers: 04/20/19, 05/08/19 and 05/10/19. There was no evidence provided to substantiate the resident was offered and refused to take a shower. l) Resident #38 On 07/01/19 at 8:45 AM, the Residents monthly activities of daily living (ADL) flow sheets for April, (MONTH) and (MONTH) 2019 were reviewed. Documentation on the ADL record found Resident #38 received only one shower in (MONTH) and May. Three (3) showers in June. On 07/01/19 at 9:00 AM, the ADL records were reviewed with Registered Nurse (RN) #131, the corporate clinical quality specialist. RN #131 confirmed the resident should receive two showers a week, on Monday and Thursday. RN #131 confirmed she could not find any evidence the showers were offered but not provided due to any refusal by the resident. RN #131 reviewed the ADL record for April, (MONTH) and (MONTH) and verified the documentation noted the resident had only 1 shower in April, 1 shower in May, and 3 showers in (MONTH) 2019. If the resident received his showers on Mondays and Thursdays, he should have received a total of 9 showers in April, 9 showers in (MONTH) and 8 showers in June. A total of 26 showers should have been provided, the Resident received only 4 showers. On 07/01/19 at 3:24 PM, the director of nursing (DON) reviewed the ADL records for April, (MONTH) and (MONTH) 2019. The DON was unable to provide any evidence the resident received any more showers other than the ones documented on the ADL record. m) Resident #1 Observations of Resident #1 at 11:48 a.m. on 06/24/19 found the resident to be unshaven. A review of the facility's shower schedule on 07/01/19 at 8:45 a.m. found Resident #1 should be showered every Monday and Thursday. A review of Resident #1's Activity of Daily Living Flow Sheets for the time period of 04/01/19 through current found Resident #1 only received a shower on the following dates: --04/01/19; --04/08/19; --04/09/19; --04/11/19; --04/15/19; --04/26/19; --06/06/19 and --06/16/19. The resident received no showers in the month of 05/2019. Resident #1 had no documented refusals of showers and only received showered eight (8) of his scheduled 26 showers in the last three (3) months. An interview with the Director of Nursing at 10:45 a.m. on 07/01/19 reviewed the ADL flow sheets and agreed Resident #1 had not received his showers as scheduled. She stated that when a male resident is showered he should also be shaved. n) Resident #68 Observations of Resident #68 at 3:43 p.m. on 06/24/19 found the resident to be unshaven. A review of the facility's shower schedule on 07/01/19 at 9:00 a.m. found Resident #68 should be showered every Monday and Thursday. A review of Resident #68's ADL Flow Sheets for the time period of 05/09/19 (date of admission) through current found Resident #68 only received a shower on the following dates: --05/24/19; --05/29/19; --06/03/19; --06/07/19; --06/17/19 and --06/25/19. Resident #68 had no documented refusals of showers and only received showered six (6) of his scheduled 16 showers since his admission on 05/09/19. An interview with the Director of Nursing at 10:45 a.m. on 07/01/19 reviewed the ADL flow sheets and agreed Resident #1 had not received his showers as scheduled. She also stated that a male resident should be shaved when his showered. o) Resident #101 Observations of Resident #101 at 2:48 p.m. on 06/24/19 found the resident wearing an unclean night gown. A review of the facility's shower schedule on 07/01/19 at 9:05 a.m. found Resident #101 should be showered every Tuesday and Friday. A review of Resident #101's ADL Flow Sheets for the time period of 04/01/19 through current found Resident #101 only received a shower on the following dates: 04/23/19 and 06/17/19. Resident #101 had documented shower refusals documented on the ADL flow sheet on the following days: 04/02/19; 04/19/19 and 05/19/19. Resident had no showers in the Month of 06/2019. Resident #101 had only three (3) documented refusals and only received two (2) of her scheduled 26 showers in the last three (3) months. An interview with the Director of Nursing at 10:45 a.m. on 07/01/19 reviewed the ADL flow sheets and agreed Resident #101 had not received her showers as scheduled. p) Resident #51 Observations of Resident #51 at 3:01 p.m. on 06/24/19 found the resident to be unshaven and his face had patches of dry flaky skin. A review of the facility's shower schedule on 07/01/19 at 8:55 a.m. found Resident #51 should be showered every Wednesday and Saturday. A review of Resident #51's Activity of Daily Living Flow Sheets for the time period of 04/01/19 through current found Resident #51 only received a shower on the following dates: 04/06/19; 04/14/19; 04/26/19 and 05/19/19. The resident received no showers in the month of 06/2019. Resident #51 had no documented refusals of showers and only received showers four (4) of his scheduled 26 showers in the last three (3) months. An interview with the Director of Nursing at 10:45 a.m. on 07/01/19 reviewed the ADL flow sheets and agreed Resident #51 had not received his showers as scheduled. She indicated that males should be shaved when they are showered. q) Resident #70 A review of the facility's shower schedule on 07/01/19 9:20 a.m. found Resident #70 should be showered every Tuesday and Friday. A review of Resident #70's ADL Flow Sheets for the time period of 04/01/19 through current found Resident #70 only received a shower on the following dates: --04/02/19; --04/07/19; --04/09/19; --04/16/19; --04/23/19; --04/30/19; --05/07/19; --05/14/19; --05/21/19; --05/28/19; --06/04/19; --06/18/19; --06/26/19 and --06/30/19. Resident #70 had no documented refusals of showers and only received showered 14 of her scheduled 26 showers in the last three (3) months. An interview with the Director of Nursing at 10:45 a.m. on 07/01/19 reviewed the ADL flow sheets and agreed Resident #70 had not received her showers as scheduled. r) Resident #94 During an interview with Resident #94 at 3:10 p.m. on 06/24/19 she stated she had only received two (2) showers since her admission to the facility in (MONTH) of 2019. She stated that her hair was greasy and she had to get it cut like that. The residents hair did appear to unclean and she had an odor which suggested she had not had a shower recently. Review of the facility's shower schedule at 1:30 p.m. on 06/26/19 found Resident #94 should be showered every Wednesday and Saturday. A review of Resident #94's ADL Flow Sheets for the time period of 02/19/19 (date of residents admission) through current found Resident #94 only received a shower on the following dates: 02/27/19; 04/06/19; 04/17/19 and 05/29/19. Resident had no showers in the Month of 06/2019. Resident #94 had only two (2) documented refusals and only received four (4) of her scheduled 37 showers. An interview with Nursing Home Administrator, and Director of Nursing at 2:06 p.m. on 06/26/19 confirmed Resident #94 had not received her showers as scheduled. They reviewed the ADL documentation and confirmed this would be the only place a shower or refusal would be documented. s) Resident #26 On 07/01/19 at 2:17 PM, a review of Activities of Daily Living (ADL) documents, revealed Resident #26 received zero (0) showers in the month of June. This resident was scheduled to receive two (2) showers a week, on Wednesday and Saturday. This was an opportunity to receive nine (9) showers. On 07/01/19 at 3:10 PM, an interview with Director of Nursing (DoN) confirmed the resident had not received their showers as scheduled. t) Resident #56 On 07/01/19 at 2:20 PM, a review of Activities of Daily Living (ADL) documents, revealed Resident #56 was scheduled to receive two (2) showers a week on Thursday and Sunday, this Resident had the opportunity to receive eight (8) showers for the month of June. This resident received zero (0) showers in the month of June. On 07/01/19 at 3:10 PM, an interview with Director of Nursing (DoN) confirmed the resident had not received their showers as scheduled. u) Resident #97 During a review of Activities of Daily Living (ADL) documents, revealed Resident #97 was scheduled to receive two (2) showers a week on Thursday and Monday, this was nine (9) shower this resident should have received. This resident received two (2) showers in the month of (MONTH) on 06/ 06/19 and 06/17/19. On 07/01/19 at 3:10 PM, an interview with Director of Nursing (DoN) confirmed the resident had not received their showers as scheduled. v) Resident #58 On 07/01/19 at 2:36 PM, a review of Activities of Daily Living (ADL) documents, revealed Resident #58 was scheduled to receive two (2) showers a week on Wednesday and Saturday this was nine (9) shower this resident should have received. This resident received Zero (0) showers in June. On 07/01/19 at 3:10 PM, an interview with Director of Nursing (DoN) confirmed the resident had not received their showers as scheduled. w) Resident #59 On 07/01/19 at 2:39 PM, a review of Activities of Daily Living (ADL) documents, revealed Resident #59 was scheduled to receive two (2) showers a week Tuesday and Friday, this was an opportunity to receive eight (8) showers for the month of June. This resident received one (1) shower on 06/25/19. On 07/01/19 at 3:10 PM, an interview with Director of Nursing (DoN) confirmed the resident had not received their showers as scheduled. x) Resident #69 On 07/01/19 at 2:41 PM, a review of Activities of Daily Living (ADL) documents, revealed Resident #69 was scheduled to receive two (2) showers a week Monday and Thursday. This resident had the opportunity to receive eight (8) showers and received zero (0) showers in June. On 07/01/19 at 3:10 PM, an interview with Director of Nursing (DoN) confirmed the resident had not received their showers as scheduled. y) Resident #27 On 07/01/19 at 3:02 PM, a review of Activities of Daily Living (ADL) documents, revealed Resident #27 was scheduled to receive two (2) showers a week on Monday and Thursday. That was an opportunity to receive eight (8) shower, she received only three (3) out of eight (8), on 06/03/19, 06/10/19 and 06/25/19. On 07/01/19 at 3:10 PM, an interview with Director of Nursing (DoN) confirmed the resident had not received their showers as scheduled. z) Resident #86 On 07/01/19 at 3:39 PM, a review of Activities of Daily Living (ADL) documents, revealed Resident #86 was scheduled to receive two (2) showers a week on Tuesday and Friday. This was an opportunity to have eight (8) however Resident #86 had one (1) shower on 06/12/19. On 07/01/19 at 3:40 PM, an interview with Director of Nursing (DoN) confirmed the resident had not received their showers as scheduled. aa) Resident #46 On 07/01/19 at 3:44 PM, a review of Activities of Daily Living (ADL) documents, revealed Resident #46 was scheduled to receive two (2) showers a week on Monday and Thursday. this was an opportunity to receive eight (8) showers he received one (1) showers on 06/30/19. On 07/01/19 at 350PM, an interview with Director of Nursing (DoN) confirmed the resident had not received their showers as scheduled. bb) Resident #99 On 07/01/19 at 3:47 PM, a review of Activities of Daily Living (ADL) documents, revealed Resident #99 was scheduled to receive two (2) showers a week on Wednesday and Saturday. This resident received two (2) showers on 06/05/19 and 06/17/19. On 07/01/19 at 3:50 PM, an interview with Director of Nursing (DoN) confirmed the resident had not received their showers as scheduled. cc) Resident #25 During a review of Activities of Daily Living (ADL) documents, revealed Resident #25 was scheduled to receive two (2) showers a week on Monday and Thursday. This was an opportunity to receive eight (8) showers. She received only two (2) showers on 06/19/19 and 06/30/19. On 07/01/19 at 3:10 PM, an interview with Director of Nursing (DoN) confirmed the resident had not received their showers as scheduled. dd) Resident #90 On 07/01/19 at 3:56 PM, a review of Activities of Daily Living (ADL) documents, revealed Resident #90 was scheduled to receive two (2) showers a week on Tuesday and Friday. This resident received two (2) on 06/04/19 and 06/18/19. On 07/01/19 at 4:10 PM, an interview with Director of Nursing (DoN) confirmed the resident had not received their showers as scheduled. ee) Resident #76 On 07/01/19 at 4:03 PM, a review of Activities of Daily Living (ADL) documents, revealed Resident #76 was scheduled to receive two (2) showers a week on Wednesday and Saturday. This resident received one (1) shower on 6/30/19. On 07/01/19 at 4:10 PM, an interview with Director of Nursing (DoN) confirmed the resident had not received their showers as scheduled. ff) Resident #89 On 07/01/19 04:07 PM, a review of Activities of Daily Living (ADL) documents, revealed Resident #89 was scheduled to receive two (2) showers a week Tuesday and Friday. This resident received one (1) shower on 06/12/19 for June. On 07/01/19 at 4:10 PM, an interview with Director of Nursing (DoN) confirmed the resident had not received their showers as scheduled. gg) Resident #8 During a review of Activities of Daily Living (ADL) documents, revealed Resident #8 was scheduled to receive two (2) showers a week Monday and Thursday. This resident had the opportunity to receive eight (8) showers. This resident received zero (0). On 07/01/19 at 4:10 PM, an interview with Director of Nursing (DoN) confirmed the resident had not received their showers as scheduled. hh) Resident #16 During a review of Activities of Daily Living (ADL) documents, revealed Resident #16 was scheduled to receive two (2) showers a week Monday and Thursday, this was an opportunity to receive eight (8) showers. This resident received one (1) shower on 06/20/19. On 07/01/19 at 4:10 PM, an interview with Director of Nursing (DoN) confirmed the resident had not received their showers as scheduled. ii) Resident #49 During an interview on 06/24/19 Resident stated, I would like to get more showers, since I have moved over here (Maple Unit) I hardly get any. I am supposed to get at least two (2) a week. Resident was noted to have transferred from Dogwood Unit room [ROOM NUMBER]A to Maple unit room [ROOM NUMBER]B on 05/13/19. Review of Activities of Daily Living (ADL) sheets for Resident #49 revealed Resident received showers for only 4 out of 8 opportunities in May, and 4 out 9 opportunities in June. Shower schedule for when Resident was residing in room [ROOM NUMBER]A in the Dogwood unit was Monday and Thursday. The shower schedule for the Maple Unit while Resident was residing in room [ROOM NUMBER]B was Wednesday and Saturday. After Resident was transferred from room [ROOM NUMBER]A to room [ROOM NUMBER]B on 05/13/19, the Resident went from 5/15/19 - 5/18/19 (4 days in a row) without any type without any type of bathing, and only received two (2) showers (on 06/14/19, and 06/25/19) thereafter through the end of June. Review of Resident's care plan revealed an active focus point that indicated the Resident is at risk for decreased ability to perform ADL(s) care related to: [MEDICAL CONDITION], resident has hx refusing showers, cognitive loss, dementia, recent cervical fracture, with a goal for the Resident to maintain highest capable level of ADL ability throughout the next review period and an intervention that stated, Provide resident with total assist of 1 for bathing. On 07/02/19, DON agreed that the Resident did not receive adequate bathing of her choice, and someone should have caught the issue by now by reviewing the ADL sheets. jj) Resident #106 During an interview on 06/25/19 at 10:30 AM, Resident stated, Not enough showers. I never get bathed on the weekends, they act like I am irritating them. Review of Residents Activity of Daily Living (ADL) sheets for the past two (2) months revealed the Resident was only provided with a bed bath during bathing, no documentation that a shower was ever given or refused. The Resident was not provided with any type of bathing for the following dates: --05/04/19 - Saturday --05/05/19 - Sunday --05/11/19 - Saturday --05/17/19 - Friday --05/18/19 - Saturday --05/19/19 - Sunday --05/24/19 - Friday --05/25/19 - Saturday --05/26/19 - Sunday --06/08/19 - Saturday --06/29/19 - Saturday --06/30/19 - Sunday Review of Dogwood Shower List (unit of which Resident resided) indicated Resident's shower schedule was to be every Tuesday and Friday. Review of Residents care plan revealed an active focus area for bathing that stated: Resident requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to [MEDICAL CONDITION], Dementia, with an intervention of, Provide resident with total assist of 1 for bathing. On 07/02/19 at 9:19 AM, Director of Nursing (DON) agreed that the Resident did not receive any bathing during the weekends as indicated for the dates in (MONTH) and (MONTH) and no documentation existed to indicate the Resident had refused.",2020-09-01
859,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,679,D,0,1,LUON11,"Based on resident interview, record review, staff interview and policy review, the facility failed to implement an ongoing resident centered activity program that incorporated Resident #49's preferences of church services. This was true for 1 of 3 residents reviewed for activities. Resident identifier: #49. Facility census: 117. a) Resident #49 During initial screening process on 06/24/19 at 10:56 AM Resident stated she would like to have church every Sunday instead of just once or twice a month. Review of Activities Calendar for the month of (MONTH) 2019 revealed the facility only provided the Resident with one (1) out of (5) opportunities to attend church worship service on Sunday. On 07/01/19 at 8:40 AM during an interview the Activities Director (AD) verified the (MONTH) Activity calendar to only include one (1) opportunity for the Resident to attend church services on Sunday (06/02/19) for the month of June. AD stated activities such as Father's Day celebration, bird watching, and bowling replaced the opportunity for church services on the other Sundays of the month. Review of the Facility's policy REC200 titled Resident/Patient's Choice stated Residents/Patients have the right to participate in leisure and recreation of their choosing. Review of the Facility's policy REC201 titled Spiritual Support stated spiritual and religious activities will be available to residents and their families on a routine basis, including worship services. Review of Resident's care plan revealed an activity focus point that stated, (Resident's first name) stated that it is important that she has the opportunity engage in daily routines that are meaningful relative to their preferences, with a goal the Resident will plan and choose to engage in preferred activities daily, and an intervention that stated:, Encourage and facilitate residents/patients activity preferences daily chronical, bingo, church service, special events, music. During an interview on 07/2/19 at 9:00 AM, social services specialist #96 stated, We (the facility) have piano playing, hymns, and bible study on Tuesdays. But you are right, we don't have actual church",2020-09-01
860,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,684,E,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interviews the facility failed to provide the necessary care and services to ensure each resident is able attain or maintain this highest practicable physical mental and psychosocial well-being. This was true for nine (9) of forty (40) sampled residents. Resident #78 did not receive an anticoagulant ([MEDICATION NAME]) on two (2) separate occasions. Residents #162, #53, and #92 did not receive medication as ordered in a timely manner. Resident #211's activities of daily living (ADL) was not documented for several days after admission. Resident #111 was not assessed for ADLs to prevent a hospitalization and after a head injury the facility failed to do neurological assessments. For Resident #161, the facility failed to monitor bowel movements. For Resident #31, failed to provide wound care as ordered. For Resident #49, the facility failed to do neurological checks accurately. Resident identifiers: #78, #162, #53, #92, #211, #111, #161, #31 and #48. Facility census: 117. Findings included: a) Resident #78 Review of Resident #78's medical records found the resident was admitted to the facility on [DATE]. Medications included [MEDICATION NAME] (anticoagulant) for treatment of [REDACTED]. On 05/31/19 the PT/INR results were received, and new orders obtained to increase [MEDICATION NAME] to 5.5 milligrams (mg). Review of the Medication Administration Record [REDACTED]. On 06/19/19 the PT/INR results were received, and new orders obtained to restart [MEDICATION NAME] 4 mg. Review of the Medication Administration Record [REDACTED]. On 06/26/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive his [MEDICATION NAME] on 05/31/19 and 06/19/19 as ordered. No further information provided. b) Resident #162 Interview with Resident #53 and #92 on 06/24/19 at 11:45 am. During this interview they stated, I don't get my medication due at 9:00 pm until late some nights especially 06/22/19. We also asked for a pain pill and had to wait another hour to get it. We were very frightened due to the resident (#162) had become upset and threw an oxygen cylinder out in the hallway. We were afraid it would blow us up. Review of 162's medical records found no mention of the above incident occurring. On 06/25/19 at 11:00 am the DON was asked about the above incident on evening shift from 06/22/19 thru 06/25/19. She stated, I am not aware of anything occurring on any of these dates. According to an anonymous interview, Resident #162 became upset on the evening of 06/22/19 and did throw her oxygen cylinder out in the hallway. Resident #162 was upset because she felt the nurse was withholding her medication. Review of Resident #162's electronic Medication Administration Audit Report for 06/22/19, found the medication ordered for 9:00 pm (Trazadone, [MEDICATION NAME], Atorvastatin and [MEDICATION NAME]) was not administered by Employee #57, registered nurse (RN) until six (6) hours after the scheduled time at 3:07 am on 06/23/19. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive medications as scheduled on 06/22/19. She confirmed on review of the medication administration times the above mentioned they were documented as given at 3:07 am on 06/23/19. She agreed this was six (6) hours after the scheduled time. A verbal statement dated 07/01/19 with no time documented, from Employee #54, RN read: (typed as written) (Resident #162's name) came out into the hallway requesting pain medication. Nurse informed her that it was not time for her pain medication. (Resident #162's name) then became upset and started to scream and throw things in her room. She threw her water pitcher, threw clothing items, threw her Bi-pap machine across the room, and then proceeded to throw an oxygen cylinder into the hallway. Nurse went into the room and attempted to calm patient explaining to her that she could have her pain medication at 9 pm when it was scheduled and that she is scheduled twice a day dose receiving it at 9 am and 9 pm. After redirecting the patient with further conversation, she calmed down and had on further complaints or behaviors. NA then cleaned her room. The DON on 07/02/19 at 9:00 am stated, I spoke to Employee #54, RN concerning times the medications was documented and she said, she gives all of her medications and then signs all of the medications at one time. When asked if this was the policy of the facility and she said, No. Review of the Medication Administration policy: Medications will be administered and signed immediately after administration .Doses will be administered within one (1) hour of the prescribed time unless otherwise indicated by the prescriber If unable to provide the medication (s) within one hour of prescribed time, refer to Medication errors policy . No further information provided. c) Resident #53 Interview with Resident #53 and #92 on 06/24/19 at 11:45 am. During this interview they stated, I don't get my medication due at 9:00 pm until late some nights especially 06/22/19. We also asked for a pain pill and had to wait another hour to get it. We were very frightened due to the resident (#162) had become upset and threw an oxygen cylinder out in the hallway. We were afraid it would blow us up. Review of Resident #53's electronic Medication Administration Audit Report for 06/22/19, found the medication ordered for 9:00 pm ([MEDICATION NAME], [MEDICATION NAME] and Klonopin) was not administered by Employee #57, registered nurse (RN) until six (6) hours after the scheduled time at 3:11 am on 06/23/19. No documentation Resident #53 was provided a pain medication (Tylenol) on 06/22/19 or 06/23/19. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive medications as scheduled on 06/22/19. She confirmed on review of the medication administration times the above mentioned they were documented as given at 3:11 am on 06/23/19. She agreed this was six (6) hours after the scheduled time. The DON on 07/02/19 at 9:00 am stated, I spoke to Employee #54, RN concerning times the medications was documented and she said, she gives all of her medications and then signs all of the medications at one time. When asked if this was the policy of the facility and she said, No. Review of the Medication Administration policy: Medications will be administered and signed immediately after administration .Doses will be administered within one (1) hour of the prescribed time unless otherwise indicated by the prescriber If unable to provide the medication (s) within one hour of prescribed time, refer to Medication errors policy . No further information provided. d) Resident #92 Interview with Resident #53 and #92 on 06/24/19 at 11:45 am. During this interview they stated, I don't get my medication due at 9:00 pm until late some nights especially 06/22/19. We also asked for a pain pill and had to wait another hour to get it. We were very frightened due to the resident (#162) had become upset and threw an oxygen cylinder out in the hallway. We were afraid it would blow us up. Review of Resident #92's electronic Medication Administration Record [REDACTED]. No documentation Resident #92 was provided a pain medication (Tylenol) on 06/22/19 or 06/23/19. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive medications as scheduled on 06/22/19. She confirmed on review of the medication administration times the above mentioned they were documented as given at 3:11 am on 06/23/19. She agreed this was six (6) hours after the scheduled time. The DON on 07/02/19 at 9:00 am stated, I spoke to Employee #54, RN concerning times the medications was documented and she said, she gives all of her medications and then signs all of the medications at one time. When asked if this was the policy of the facility and she said, No. Review of the Medication Administration policy: Medications will be administered and signed immediately after administration .Doses will be administered within one (1) hour of the prescribed time unless otherwise indicated by the prescriber If unable to provide the medication (s) within one hour of prescribed time, refer to Medication errors policy . No further information provided. e) Resident #211 Review of Resident #211's medical records found the resident was admitted to the facility on [DATE]. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found no documentation until 06/23/19. (5 days later) On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident had no documentation existed until 06/23/19 to indicate the ADLs were provided until five days after admission. No further information provided. f) Resident #111 Review of Resident #111's medical records found this resident was admitted to the facility on [DATE] at 6:39 pm, from an acute care facility with [DIAGNOSES REDACTED]. Noted to have impairment of right upper extremity and weakness in the right arm and both legs. Review of the interim care plan dated 02/03/19 found no directions for assistance required to provide Activities of Daily Living (ADL)s which includes bed mobility, transfers, eating, toileting, dressing, grooming, and bathing. Resident #111's experienced a fall on 02/03/19 at 3:30 pm. Resident's progress note states, Resident was being changed by nurse aide at 3:30 pm. Resident was rolling to the right hand side of the bed when the resident rolled herself from the bed to the floor, the bed was raised to waist height as the aide was performing care on the resident. Post fall the resident c/o (complained of) severe left knee and left rib pain. This nurse contacted the on-call physician who gave orders to have resident sent out to the emergency room to be evaluated for potential fractures. Nurse aide who was performing care will complete a statement regarding the incident. Bruise noted on left knee and left cheek. Review of policy for Falls Management reads: Perform neurological assessment for all unwitnessed falls and witnessed falls with head injury This survey requested the statement from the nurse aide providing care for Resident #111 on 02/03/19 at 3:30 pm and neurological checks. No information was provided. emergency room report status [REDACTED]. No fractures or dislocations noted. Resident #111 was seen and examined by the attending physician on 02/04/19. Progress note states, She reports that yesterday she rolled out of bed onto her face during change and hit her face and knee. She was transferred to (name of hospital) where x-rays were done, and they were negative for fracture. She complains of severe pain around the left side of face Mild bruising and tenderness noted around the left periorbital area Resident was evaluated by physical and occupational therapy on 02/04/19. An assessment dated [DATE] at 1:59 performed by a registered nurse (RN) which indicates the resident requires extensive assistance of two or more persons for bed mobility. Interview with the Director of Nursing (DON) on 07/01/19 at 1:10 pm. Resident #111's medical records were reviewed by the DON. She confirmed no neuro checks and nurse aide statement could be located concerning the 02/03/19 incident. She also confirmed the licensed staff had not evaluated the assistance needed for bed mobility and no directions for care was provided to the direct care staff. No further information provided. g) Resident #161 Medical record review on 06/26/19 at 1:00 PM, found the resident was admitted to the facility from a hospital on [DATE]. Review of the activities of daily living (ADL) record found the first bowel movement, recorded after admission was on 04/25/19, 16 days after admission. Review of the admission minimum data set (MDS) with an assessment reference date (ARD) of 04/17/19, found the resident was always incontinent of bowel and she required total dependence of two plus staff members for toileting. The resident was unable to walk or transfer herself to a wheelchair. Therefore, the resident could not have toileted herself without staff knowledge. At 3:02 PM on 06/26/19, the Registered Nurse (RN) corporate quality specialist and the director of nursing (DON) reviewed the ADL flow sheet. The DON reviewed the Medication Administration Record [REDACTED]. The DON was unable to provide evidence of any bowel movements documented elsewhere during the time period of 04/10/19 to 04/24/19. At 9:41 AM on 07/01/19, a Registered Nurse (RN) corporate clinical quality specialist RN #131 and the DON reviewed the ADL flow sheet. The DON said she would have expected someone to be monitoring the ADL flow sheets and that someone should have brought this information to the morning meeting so action could be taken. The DON provided a copy of the facility's standing order for constipation: If no bowel movement in three days, give milk of magnesia 30 ml by mouth one dose at bedtime. If no bowel movement within next shift, give [MEDICATION NAME] suppository PR x one If no bowel movement within two hours, give fleet enema If no results from Fleet enema, call physician/advanced practice provider for further orders. At the close of the survey on 07/02/19 at 1:00 PM, no evidence was provided by the facility to indicate the facility was aware there were no bowel movements documented for 16 days and no evidence to substantiate the facility had taken any action to eliminate the residents constipation . h) Resident #49 On 06/27/19 at 12:05 PM, review of medical records indicated Neurological (Neuro) checks (a brief neurological assessment ordered by the physician to monitor resident for neurological compromise after a fall, consisting of assessments of level of consciousness, motor response, pupil response, pain, and vital signs) were not accurately completed for the Resident after a fall on 04/21/19 that resulted in a head injury. Level of consciousness was not completed for 9 of 16 neuro-checks that were performed for the Resident. Neuro-checks were not implemented until 04/22/19 at 10:00 AM for Resident's fall that occurred on 04/21/19 at 11:45 AM. The Resident was out of facility for evaluation of a laceration to left eye brow that occurred during the fall until 7:45 PM on 04/21/19. During an interview on 07/02/19 at 9:16 AM Director of Nursing (DON) verified resident was sent out of facility to the Emergency Department (ER) at 4/21/19 at 11:45 AM and returned to facility at 7:45 PM on 04/21/19. The DON agreed the Neuro-checks were not accurately completed for the Resident and stated, They should have been started that evening (4/21/19 at 7:45 PM) when the Resident returned to the facility from the ER. No further documentation of any additional neuro-checks was provided. i) Resident #31 Review of Resident #31's Treatment Administration Record (TAR) on 07/02/19 at 8:38 AM, showed the schedule contained the following directions for wound care, Cleanse right abdominal fold wound with wound cleanser, pat dry, apply non-adherent pad and cover with dry dressing. Every day shift. Effective date on Progress Notes was 04/25/19. For the month of May, the surgical wound was not treated on days 14, 17,18 and 25. An interview with the Director of Nursing (DON), on 07/02/19 at 8:40 AM, confirmed the wound care was not performed on those dates.",2020-09-01
861,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,687,D,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure resident #89 received proper treatment to maintain good foot health. This was a random opportunity of discovery. Resident Identifier: #89. Facility Census: 117. Findings include: a) Resident #89 Observations of Resident #89's feet with the Director of Nursing (DON) on 07/01/19 at 10:20 a.m. found the residents toe nails to be long, thick, and brown. The DON stated she needs to see the podiatrist. Later in the morning on 07/01/19 the DON provided the Podiatrist's list and stated the resident was scheduled to see him on 07/10/19. An interview with Social Worker #96 at 11:39 a.m. on 07/01/19 found the Podiatrist comes to the facility every three months. She indicated the Podiatrist was last at the facility on 04/17/19 to 04/18/19 and Resident #89 was not seen on that date. An additional interview with DON at 12:37 p.m. on 07/01/19 confirmed Resident #89 was admitted to the facility on [DATE] and should have been added to the list to see the podiatrist when he as at the facility on 04/17/19 and 04/18/19. She stated that he toe nails are too thick and the nurses would not be able to trim them.",2020-09-01
862,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,688,E,0,1,LUON11,"**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 received restorative therapy to improve, maintain, or prevent a decline in range of motion. This was true for four (4) of forty (40) residents reviewed. Resident identifier: #38. Facility census: 117. Findings include: a) Resident #38 Record review on 06/27/19 at 10:00 AM, revealed an order for [REDACTED]. At 10:22 AM on 06/27/19, the Registered Nurse (RN)#50, who oversees the restorative program, and the restorative aide RA#19, reviewed the restorative nursing record and confirmed there was no evidence to verify the resident received any restorative therapy. RN#50 said RA#19 said they were frequently pulled from the restorative program to work the floor because enough nursing assistants did not show up for work. RA#19 said she was unable to provide restorative nursing services because she was working as a nursing assistant. RN#50 said at times she has to work on the floor as a nurse. On 06/27/19 at 11:44 AM, the administrator said, when restorative is pulled to work the floor the nursing assistants are supposed to provide restorative therapy. The administrator was asked if she was aware there was no documentation of the restorative nursing record. She replied, no. When asked if the facility reviews restorative nursing services during the monthly Quality Assurance and Assessment (QAA) meetings, the administrator said, yes, a report is reviewed. The administrator said RN #50 had not reported any problems with providing restorative therapy. b) Resident #53 Interview with Resident #53 on 06/24/19 at 1:30 pm found the resident voiced, There is not enough staff for me to get my restorative exercises. Medical record review for Resident #53 found a physician order [REDACTED]. (pound) weights in all planes, 3 x a week for 6 weeks and resident to ambulate 100 feet times 2 with rolling walker and contact guard assistance (CGA), 3 x weekly for 6 weeks. Review of the Restorative Nursing Record found the restorative program written on 06/03/19 was not initiated till 06/10/19. Additionally, from 06/22/19 through 06/30/19 the restorative program was not received. Interview with the Director of Nursing (DON) on 06/27/19 at 12:15 pm, confirmed the restorative program for Resident #53 did not start and had not been provided as physician's orders [REDACTED]. c) Resident #80 During an interview on 06/25/19 at 9:35 AM, Resident #80 said, that she was supposed to have restorative care, but took the restorative nurse aide and put that her on the floor. Now I am not getting it twice a week any more. She went on to say, that she tries to do it herself, but cannot do the standing part alone. She said, that she could stand with help and now she cannot. She stated, that the last time she got to stand up was the last part (MONTH) or first of May. She stated, that she feels as though she has lost a lot time and has lost her strength again. Physician order [REDACTED]. Review of the medical record titled, Restorative Nursing Record dated; (MONTH) 2019. Revealed the following: Goals: Standing in parallel bars with moderate assistance as tolerated. Three (3) times a week for six (6) weeks. End date: 06/24/19. This report showed no evidence of restorative care from 06/01/19 to 06/12/19. She received restorative care Three (3) times (06/13/19, 06/19/19, 06/22/19) in (MONTH) out of an opportunity to receive this care 14 times. During an interview on 06/27/19 at 10:00 AM, Registered Nurse (RN)#50, (who is also the restorative nurse) stated, that Aide Restorative Nurse (ARN) #19 had been doing restorative for [AGE] years. She stated that she ca not do anything about ARN #19 being pulled to be a nurse aide, instead of just restorative. She went on to say, that the nurse aides are supposed to be providing the restorative care. During an interview on 06/27/19 at 10:09 AM, ARN #19 was asked how much training she did have as a restorative nurse. She stated that she had worked with physical therapy [AGE] years and [AGE] years of restorative. She became tearful and stated, It breaks my heart that I can't help these people. I know they aren't getting what they need, but I'm killing myself trying to do my job as a nurse aide and then every time I get a minute, I try to do some restorative care. I just can't do it all. During an interview on 06/27/19 at 11:47 AM, Administrator stated, that the Nurse Aides (NA) are supposed to be doing the restorative care. She was asked if she was aware NA were trained to provide the restorative care as ordered. She said, that in her experience the Physical Therapy tells the NA how the continue with the restorative care, but she was not sure about the standing with the parallel bars. She also stated, that she could not provide any type of documentation to show that they were shown what to do. d) Resident #6 During an interview on 06/25/19 at 11:43 AM, Resident #6 stated, that he has not received restorative care lately, because they had to pull ARN #19 to the floor to be an aide. Physician order [REDACTED]. For complete Passive Range of Motion (PROM) Bilateral Lower Extremity (BLE) to all planes, move slow to decrease [DIAGNOSES REDACTED]. A review of the medical record titled, Restorative Nursing Record dated: (MONTH) 2019, revealed the following information. For this month Resident #6 had three times he refused, and zero restorative care performed the month. On 06/26/19 at 3:09 PM, Director of Nursing (DoN) was asked about the restorative care not being provided for Resident #6. She stated, that she will have to look into it. During an interview on 06/27/19 at 9:53 AM, Registered Nurse (RN)#50, (who is also the restorative nurse) was asked why there was so many holes are on the Restorative Nursing Record. She stated, that it was like that, because she has one restorative nurse aide and she has been pulled to the floor. She was asked what do the empty wholes mean. She said, that it would mean that, they were not done. She said, that the other Nurse Aides (NA) are not trained to be a restorative nurse aide, but they can do some Range of Motion (ROM), but probably as good as job as ARN #19 would do. During an interview on 06/27/19 11:44 AM, Administrator was asked if the residents were receiving restorative care when ARN #19 is pulled to work on the floor as a Nurse Aide (NA). She stated, that the NA's are supposed to do the restorative. She said, that they are doing it. This is a lack of documentation. She that, if it would have been identified we would have been looking at it in Quality Assurance (QA), but we did not know that the records were blank.",2020-09-01
863,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,689,E,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interviews, and observation, the facility failed to ensure each resident's environment remain as free of accident hazards as is possible; and ensure each resident receives adequate supervision and assistance devices to prevent accidents. This was true for three (3) of eight (8) reviewed for falls and one (1) random opportunity for discovery. Resident identifiers: #111, #162, #53, #92, #49. Facility census: 117. Findings included: a) Resident #111 Review of Resident #111's medical records found this resident was admitted to the facility on [DATE] at 6:39 pm, from an acute care facility with [DIAGNOSES REDACTED]. Noted to have impairment of right upper extremity and weakness in the right arm and both legs. Review of the interim care plan dated 02/03/19 found no directions for assistance required to provide Activities of Daily Living (ADL)s which includes bed mobility, transfers, eating, toileting, dressing, grooming, and bathing. Resident #111's experienced a fall on 02/03/19 at 3:30 pm. Resident's progress note states, Resident was being changed by nurse aide at 3:30 pm. Resident was rolling to the right hand side of the bed when the resident rolled herself from the bed to the floor, the bed was raised to waist height as the aide was performing care on the resident. Post fall the resident c/o (complained of) severe left knee and left rib pain. This nurse contacted the on-call physician who gave orders to have resident sent out to the emergency room to be evaluated for potential fractures. Nurse aide who was performing care will complete a statement regarding the incident. Bruise noted on left knee and left cheek. Review of policy for Falls Management reads: Perform neurological assessment for all unwitnessed falls and witnessed falls with head injury This survey requested the statement from the nurse aide providing care for Resident #111 on 02/03/19 at 3:30 pm and neurological checks. No information was provided. emergency room report status [REDACTED]. No fractures or dislocations noted. Resident #111 was seen and examined by the attending physician on 02/04/19. Progress note states, She reports that yesterday she rolled out of bed onto her face during change and hit her face and knee. She was transferred to (name of hospital) where x-rays were done, and they were negative for fracture. She complains of severe pain around the left side of face Mild bruising and tenderness noted around the left periorbital area Resident was evaluated by physical and occupational therapy on 02/04/19. An assessment dated [DATE] at 1:59 performed by a registered nurse (RN) which indicates the resident requires extensive assistance of two or more persons for bed mobility. Interview with the Director of Nursing (DON) on 07/01/19 at 1:10 pm. Resident #111's medical records were reviewed by the DON. She confirmed no neuro checks and nurse aide statement could be located concerning the 02/03/19 incident. She also confirmed the licensed staff had not evaluated the assistance needed for bed mobility and no directions for care was provided to the direct care staff. No further information provided. b) Resident #162 Interview with Resident #53 and #92 on 06/24/19 at 11:45 am. During this interview they stated, I don't get my medication due at 9:00 pm until late some nights especially 06/22/19. We also asked for a pain pill and had to wait another hour to get it. We were very frightened due to the resident (#162) had become upset and threw an oxygen cylinder out in the hallway. We were afraid it would blow us up. Review of 162's medical records found no mention of the above incident occurring. On 06/25/19 at 11:00 am the DON was asked about the above incident on evening shift from 06/22/19 thru 06/25/19. She stated, I am not aware of anything occurring on any of these dates. According to an anonymous interview, Resident #162 became upset on the evening of 06/22/19 and did throw her oxygen cylinder out in the hallway. Resident #162 was upset because she felt the nurse was withholding her medication. A verbal statement dated 07/01/19 with no time documented, from Employee #54, RN read: (typed as written) (Resident #162's name) came out into the hallway requesting pain medication. Nurse informed her that it was not time for her pain medication. (Resident #162's name) then became upset and started to scream and throw things in her room. She threw her water pitcher, threw clothing items, threw her Bi-pap machine across the room, and then proceeded to throw an oxygen cylinder into the hallway. Nurse went into the room and attempted to calm patient explaining to her that she could have her pain medication at 9 pm when it was scheduled and that she is scheduled twice a day dose receiving it at 9 am and 9 pm. After redirecting the patient with further conversation, she calmed down and had on further complaints or behaviors. NA then cleaned her room. Director of Nursing (DON) agreed on 07/02/19 at 10:15 am, the above-mentioned incident was an accident hazard. No further information provided. c) Resident #53 Interview with Resident #53 and #92 on 06/24/19 at 11:45 am. During this interview they stated, I don't get my medication due at 9:00 pm until late some nights especially 06/22/19. We also asked for a pain pill and had to wait another hour to get it. We were very frightened due to the resident (#162) had become upset and threw an oxygen cylinder out in the hallway. We were afraid it would blow us up. Review of 162's medical records found no mention of the above incident occurring. On 06/25/19 at 11:00 am the DON was asked about the above incident on evening shift from 06/22/19 thru 06/25/19. She stated, I am not aware of anything occurring on any of these dates. According to an anonymous interview, Resident #162 became upset on the evening of 06/22/19 and did throw her oxygen cylinder out in the hallway. Resident #162 was upset because she felt the nurse was withholding her medication. A verbal statement dated 07/01/19 with no time documented, from Employee #54, RN read: (typed as written) (Resident #162's name) came out into the hallway requesting pain medication. Nurse informed her that it was not time for her pain medication. (Resident #162's name) then became upset and started to scream and throw things in her room. She threw her water pitcher, threw clothing items, threw her Bi-pap machine across the room, and then proceeded to throw an oxygen cylinder into the hallway. Nurse went into the room and attempted to calm patient explaining to her that she could have her pain medication at 9 pm when it was scheduled and that she is scheduled twice a day dose receiving it at 9 am and 9 pm. After redirecting the patient with further conversation, she calmed down and had on further complaints or behaviors. NA then cleaned her room. Director of Nursing (DON) agreed on 07/02/19 at 10:15 am, the above-mentioned incident was an accident hazard. No further information provided. d) Resident #92 Interview with Resident #92 and #53 on 06/24/19 at 11:45 am. During this interview they stated, I don't get my medication due at 9:00 pm until late some nights especially 06/22/19. We also asked for a pain pill and had to wait another hour to get it. We were very frightened due to the resident (#162) had become upset and threw an oxygen cylinder out in the hallway. We were afraid it would blow us up. Review of 162's medical records found no mention of the above incident occurring. On 06/25/19 at 11:00 am the DON was asked about the above incident on evening shift from 06/22/19 thru 06/25/19. She stated, I am not aware of anything occurring on any of these dates. According to an anonymous interview, Resident #162 became upset on the evening of 06/22/19 and did throw her oxygen cylinder out in the hallway. Resident #162 was upset because she felt the nurse was withholding her medication. A verbal statement dated 07/01/19 with no time documented, from Employee #54, RN read: (typed as written) (Resident #162's name) came out into the hallway requesting pain medication. Nurse informed her that it was not time for her pain medication. (Resident #162's name) then became upset and started to scream and throw things in her room. She threw her water pitcher, threw clothing items, threw her Bi-pap machine across the room, and then proceeded to throw an oxygen cylinder into the hallway. Nurse went into the room and attempted to calm patient explaining to her that she could have her pain medication at 9 pm when it was scheduled and that she is scheduled twice a day dose receiving it at 9 am and 9 pm. After redirecting the patient with further conversation, she calmed down and had on further complaints or behaviors. NA then cleaned her room. Director of Nursing (DON) agreed on 07/02/19 at 10:15 am, the above-mentioned incident was an accident hazard. No further information provided. e) Unidentified pill in shower room floor. During a tour on 06/30/19 at 9:50 PM, of the shower room on the 200 hall, it was notied that a small blue pill was laying on the floor in the shower room which was accessible to any mobile resident. The shower room door was blocked open. Licensed Practical Nurse (LPN) #71 verified that it was a pill on the floor and any resident could have got the pill. She also stated, that she is not sure what the pill is. During an interview on 07/01/19 at 10:00 AM, Director of Nursing was informed about the blue pill in the shower room floor. f) Resident #49 Review of Residents care plan revealed a focus area of fall preventions that included an intervention initiated on 03/25/19 for non-skid strips to be implemented and used in in the Resident's room on the right side of the Resident's bed. On 07/01/19 at 10:00 AM, observation of Resident's room (room [ROOM NUMBER]B) revealed non-skid strips were not present or in use as a fall prevention technique. At 10:17 AM on 07/01/19, RN #28 verified non-skid strips were not being used in the Resident's room (room [ROOM NUMBER]B), as indicated for fall precautions. RN stated, I bet they forgot to put those (non-skid strips) down after they moved the Resident from the other room.",2020-09-01
864,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,690,D,0,1,LUON11,"Based on observation and staff interview, the facility failed to ensure appropriate treatment and services for an indwelling suprapubic catheter. Failed to use of an anchor secure device (used to prevent tissue injury and/or accidental removal, excessive urethral tension, or obstruction of urine outflow. This was true for one (1) of one (1) reviewed for catheter care. Identified Resident # 6. Facility census 117. Findings included: a) Resident #6 On 07/01/19 at 9:14 AM, Registered Nurse (RN) #28 providing suprapubic catheter care. There was some dried blood on the old dressing that was removed and at the insertion site there was large amount of bright red bleeding. There was not a secure anchor device on Resident #6. It was pointed out to RN #28 and she agreed there should have been on this resident. On 07/01/19 at 9:35 AM, RN #28 placed a secure anchor device to the upper right leg. On 07/01/19 at 12:00 PM Director of Nursing was informed of findings.",2020-09-01
865,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,692,E,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that all residents maintained acceptable parameters of nutrition. This was true for four (4) of ten (10) residents reviewed for the care area of nutrition. Resident identifiers: #91, #92, #51 and #161, Facility Census: 117. Findings include: a) Resident #91 Medical record review for Resident #91, found the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Admission nursing assessment reviewed, no weight and/or height was obtained. Review of the admission MDS with ARD of 06/07/2019 under section K lists the weight as 128. Nutritional care plan for Resident #91 was initiated on 06/07/19 as follows: -- Focus: Resident is a potential nutritional concern related to (r/t) fair po (by mouth) intakes, [DIAGNOSES REDACTED]. -- Goal: No significant weight changes through next review. (MONTH) experience some weight fluctuations based on diuretic ([MEDICATION NAME]) treatment in place. --Interventions: Proheal (protein supplement) as ordered. Honor food preferences within meal plan. Weigh as ordered/needed and alert dietician and physician to any significant loss or gain. Monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain and abnormal labs) and report to food and nutrition/physician as indicated. Monitor intake at all meals, offer alternate choices as needed, alert dietician physician to any decline in intake. Provide diet as ordered Offer snacks. --On 06/08/19, a nutritional assessment for Resident #91, completed by the Registered Dietician (RD) with no weight and/or height recorded. Under nutritional history reads: .No height/weight available at time of assessment Review of Resident #91's weight and vitals summary found resident's height and weight was obtained on 06/11/19 at 6:35 pm. Weight 127.8 and Height 59 inches. Facility's weight and height policy reviewed and found: Patients are weighed upon admission and/or re-admission, then weekly for four (4) weeks and monthly thereafter. Patients height will be measured upon admission, re-admission, and annually and recorded in Point Click care (PCC). Purpose: To obtain baseline weight and identify significant weight change. To determine possible causes of significant weight change. To obtain baseline height. Interview on 07/02/19 at 11:10 am, with the Director of Nursing (DON) found the weight not obtained until ten (10) days after admission. She confirmed the resident's height and weight on admission and/or readmission should be obtained within 24 hours of admission/readmission. b) Resident #92 Medical record review for Resident #92, found the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Admission nursing assessment reviewed, no weight and/or height was obtained. On 06/06/19, a nutritional assessment for Resident #92, completed by the Registered Dietician (RD) with no weight and/or height recorded. Under nutritional history reads: .No height/weight available at time of assessment Nutritional care plan for Resident #92 was initiated on 06/07/19 as follows: --Focus: Resident is a potential nutritional concern related to (r/t) [DIAGNOSES REDACTED]. --Goal: No significant weight changes through next review. -- Interventions: Honor food preferences within meal plan. Weigh as ordered/needed and alert dietician and physician to any significant loss or gain. Monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain and abnormal labs) and report to food and nutrition/physician as indicated. Monitor intake at all meals, offer alternate choices as needed, alert dietician physician to any decline in intake. Provide diet as ordered Offer snacks. Review of Resident #92's weight and vitals summary found resident's height and weight was obtained on 06/12/19 at 1:25 pm. Weight 180.2 and Height 67 inches. Facility's weight and height policy reviewed and found: Patients are weighed upon admission and/or re-admission, then weekly for four (4) weeks and monthly thereafter. Patients height will be measured upon admission, re-admission, and annually and recorded in Point Click care (PCC). Purpose: To obtain baseline weight and identify significant weight change. To determine possible causes of significant weight change. To obtain baseline height. Interview on 07/02/19 at 11:10 am, with the Director of Nursing (DON) found the weight entered on Resident #92's not obtained until eleven (11) days after admission. She confirmed the resident's height and weight on admission and/or readmission should be obtained within 24 hours of admission/readmission. c) Resident #161 Record review at 9:00 AM on 06/26/19 found the Resident was admitted to the facility from the hospital on [DATE]. The resident was discharged from the facility on 05/13/19. The following weights were recorded in the facility's electronic medical record: 05/07/2019 10:37 175.0 pounds (Lbs.) 05/01/2019 15:07 174.8 Lbs 04/24/2019 17:14 186.0 Lbs 04/18/2019 13:14 186.0 Lbs 04/10/2019 16:47 191.2 Lbs The resident had a 8.47% from 04/10/19 to 05/07/19. The resident's admission minimum data set (MDS) with an assessment reference date (ARD) of 04/17/19 coded the resident as requiring extensive assistance of 1 staff member for eating. At 10:00 AM on 6/26/19, the administrator confirmed the facility does not document the daily percentage of fluid consumed by any resident. Review of the activities of daily living (ADL) record found the following days when no meal percentages were documented for the month of April, 2019: 4/12/19 -no documentation for dinner 4/14/19 no documentation for breakfast, lunch or dinner 4/15/19 no documentation for dinner 4/18/19 no documentation for dinner 4/20/19, no documentation for breakfast, lunch or dinner 4/21/19 no documentation for dinner 4/22/19 no documentation for breakfast, lunch or dinner 4/23/19 no documentation for dinner 4/24/19 no documentation for dinner 4/26/19 no documentation for dinner 4/27/19 no documentation for dinner 4/28/19 no documentation for dinner 4/29/19 no documentation for breakfast, lunch or dinner 4/30/19 no documentation for breakfast or lunch. May 2019 5/3/19 no documentation for dinner 5/4/19 no documentation for breakfast, lunch or dinner 5/5/19 no documentation for breakfast, lunch or dinner 5/6/19 no documentation for dinner 5/9/19 no documentation for breakfast or lunch 5/10/19 no documentation for breakfast, lunch or dinner 5/11/19 no documentation for breakfast, lunch or dinner 5/12/19 no documentation for breakfast, lunch or dinner The resident discharged to home on the morning of 5/13/19. On 07/01/19 at 2:05 PM, the dietary manager (DM) and the Regional dietary manager said they couldn't comment on why the facility was not monitoring the amount of meals consumed for a resident who was loosing weight. The DM said he wasn't employed at the facility at the time. The DM said he would call the registered dietician (RD). During a telephone call at approximately 3:00 PM on 07/01/19, the RD said she was aware the meal percentages where not being documented and she believed she talked to the MDS coordinator about the problem. The RD said she was concerned as it is important to know if the resident is eating the meals or refusing the meals. d) Resident #51 A review of Resident #51's medical record ar 3:22 p.m. on 07/01/19 found a nutritional assessment completed by the registered dietician (RD) on 05/07/19. Review of this assessment found the following notation under Section 9. Nutrition History: weight, diet, dining habits: Readmit/Weight Review: Diet: Regular/Liberalized with excellent po (by mouth) intakes recorded per ADL. Resident can feed self independently and make wants and needs known A review of the ADL flow sheets for Resident #51's meal intakes for 05/01/19 through 05/07/19 found Resident #51 only had meal percentages recorded for only four (4) of the 21 meals. The other 17 meals were left blank and no meal percentage was recorded. Despite this fact the RD noted that his meal percentages we excellent per the ADL flow record. Further review of the record found the following care plan related to his nutritional status: Focus Statement: Resident is a nutritional concern related to significant weight loss X 6 months and [DIAGNOSES REDACTED]. that may impact nutritional status. Goal Statement: No signficant weight changes through next review. Goal for Weight Maintenance. Interventions include: Monitor intake at all meals, offer alternate choices as needed, alert dietician and physician to any decline in intake. Further review of the ADL flow record from 05/01/19 through current found only 80 of the 183 meals for the two (2) months had a meal percentage documented. An interview with the Director of Nursing (DON) at 3:50 p.m. at 07/01/19 confirmed the residents meal percentages had not been consistently documented and the RD's assessment referred to good by mouth intake despite the fact that the majority of meals percentages were not documented. She agreed Resident #51' s parameters of nutrition could not be adequately monitored if his meal intake was not documented and monitored.",2020-09-01
866,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,725,E,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure they had 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, as determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. Findings include: a) Anonymous Resident Interviews -- You lay in a wet brief for long periods of time and it takes hours to answer lights. -- Staff stay on cell phones and don't work. The way staff treat me make me want to lie down and have it all be over. -- On a Sunday, I hit the call button and couldn't get an answer. Finally, staff answered call light and said they would be back. Never came back. That crew doesn't like me. Since that night, I have had problems. I am very pissed .they just don't want to do their damn job. Can't get a charge nurse to talk to me. come talk to him. -- I think they are short staffed it takes two or more hours to get changed on all shifts. -- Not enough staff on weekends to serve the dining room, so we must eat in our rooms. -- It takes the staff a long-time night to answer call lights. -- I cannot get help to go back to bed from chair and my neck hurts and burns. It takes two hours or more to answer call lights. -- Nights here are a disaster after 10 pm, one aide only. Weekends are the worst, even on dayshift its ridiculous. -- Takes forever to get a pain pill. -- Staffing on weekends is bad. -- It takes 2 hours for someone to respond to call light. Sometimes they don't come at all. -- The nurse aides need help I always must wait to get help. I must eat last and food is because I need assistance. Food is not good; it is nasty. The resident stated that at night there is only one nurse and one aide for 60 residents, and I must wait 45 minutes to an hour to get help. -- All staff is over worked. The staff work 16 hours a day and that is just too much. Sometimes I don't get my medicine on time. -- Not enough staff to get bathed or showers on the weekend. -- Sometimes I ring my call light, and no one comes. -- If you must go to the bathroom it takes them an hour to come and assist you, unable to hold it that long. -- You must wait a long time to get call light answer. b) Cross reference deficiency findings at F 677 c) Cross reference deficiency findings at F 688 d) Cross reference deficiency findings at F 689 e) Cross reference deficiency findings at F 692",2020-09-01
867,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,756,D,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure the pharmacist recognized and notified the physician that Resident #31 was receiving two (2) medications from the same drug class. In addition, the physician failed to provide a timely clinical rational for declining a gradual dose reduction for Resident #103. This was true of two (2) of five (5) residents reviewed receiving medications. Resident identifiers: #31 and 103. Facility census: 117. Findings included: a) Resident #31 On 07/02/19 at 11:05 AM, Review of Resident #31's Medication Administration Record [REDACTED]. Diabetic [MEDICAL CONDITION] is a type of nerve damage that can occur if you have diabetes. It most often damages nerves in the legs and feet. The MAR indicated [REDACTED]. Both of these medications were also listed in the Resident's Progress Notes. The facility's Registered Pharmacist (RPh) failed to recognize the medication duplication upon her monthly review of the Drug Regimen Review (DRR) or MAR. On 07/02/19 at 11:30 AM, Review of the Consultation Report, developed by the Facility's RPh on 05/03/19, revealed the RPh's only recommendation to the Physician was to Please discontinue Glimepiride, which is a diabetes medication. During an interview on 07/02/19 at 11:35 AM, the Director of Nursing (DON) confirmed the Resident had received a duplicate drug therapy from 05/03/19 through 05/22/19 of two medications in the same class. b) Resident #103 A review of Resident #103's medical record during the survey revealed that the facility's Consultant Pharmacist recommended via a Consultation Report form on 05/03/19 to attempt a gradual dose reduction (GDR) of Resident #103's ordered [MEDICATION NAME] and [MEDICATION NAME] medications. The form instructed to, Please provide CMS REQUIRED patient-specific rationale describing why a GDR attempt is likely to impair function or cause psychiatric instability in this individual, and provided lines upon which the rationale was to be written. The facility's Family Nurse Practitioner (FNP) signed the recommendation on 05/06/19 and agreed only to decrease the [MEDICATION NAME] medication. No information was documented on the form's provided lines to explain the clinical rationale for the declination of the GDR of [MEDICATION NAME]. The lines had been left completely blank. During the survey, a review of the facility's Medication Regimen Review policy, effective 11/28/16, revealed that an explanation as to why the recommendation was rejected should be provided by the physician or prescriber. Information regarding the clinical rationale was requested from the facility's Director of Nursing (DoN) on 07/01/19 at 9:43 AM. At 9:49 AM, the DoN provided a progress note written by the facility's FNP on 05/15/19 (nine (9) days after the [MEDICATION NAME] GDR was declined by the FNP), directing to continue providing the [MEDICATION NAME] as ordered due to behavioral issues. However, no documentation of behavioral issues was found in the medical record or in Resident #103's Minimum Data Set (MDS) assessments and no further information regarding behavioral issues was provided prior to the end of the survey.",2020-09-01
868,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,757,D,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, the facility failed to ensure medication regimens were free from unnecessary drugs for two (2) of five (5) residents. Resident identifiers: #73 and 31. Facility census: 117 Findings included: a) Resident #73 During an interview on 07/01/19 at 3:23 PM, the facility's Consultant Pharmacist (RPh) stated that the records did not have Resident #73 as having an allergy to [MEDICATION NAME]. While during a review of Resident #73's Progress Notes dated 01/26/19 found it to be stated the Resident is allergic to the antibiotic [MEDICATION NAME]. This statement is written on each of the Resident's Progress notes since he was admitted on [DATE]. At the end of Progress Note dated 05/22/19 the Nurse Practitioner (FNP) wrote Start [MEDICATION NAME] 500 mg po daily for 7 days . On the Medication Administration Record [REDACTED]. b) Resident #31 On 07/02/19 at 11:05 AM, Review of Resident #31's Medication Administration Record [REDACTED]. Diabetic [MEDICAL CONDITION] is a type of nerve damage that can occur if you have diabetes. It most often damages nerves in the legs and feet. The MAR indicated [REDACTED]. Both of these medications were also listed in the facility's Progress Notes. During an interview on 07/02/19 at 11:35 AM, the Director of Nursing (DON) confirmed the Resident had received a duplicate drug therapy from 05/03/19 through 05/22/19.",2020-09-01
869,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,758,D,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that Resident #103 and #73's drug regimens were free from unnecessary [MEDICAL CONDITION] drugs when they failed to perform Gradual Dose Reductions (GDRs) as required. This deficient practice was found for two (2) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifiers: #103, #73. Facility census: 117. Findings included: a) Resident #103 A review of Resident #103's medical record during the survey revealed that the facility's Consultant Pharmacist recommended via a Consultation Report form on 05/03/19 to attempt a gradual dose reduction (GDR) of Resident #103's ordered [MEDICATION NAME], a [MEDICAL CONDITION] medication. The form instructed to, Please provide CMS REQUIRED patient-specific rationale describing why a GDR attempt is likely to impair function or cause psychiatric instability in this individual, and provided lines upon which the rationale was to be written. The facility's Family Nurse Practitioner (FNP) signed the recommendation on 05/06/19 and indicated on the form that she declined to perform a GDR of Resident #103's [MEDICATION NAME] medication. No information was documented on the form's provided lines to explain the clinical rationale for the declination of the GDR of [MEDICATION NAME]. The lines had been left completely blank. Information regarding the clinical rationale was requested from the facility's Director of Nursing (DoN) on 07/01/19 at 9:43 AM. At 9:49 AM, the DoN provided a progress note written by the facility's FNP on 05/15/19 (nine (9) days after the [MEDICATION NAME] GDR was declined by the FNP), directing to continue providing the [MEDICATION NAME] as ordered due to behavioral issues. However, no documentation of behavioral issues was found in the medical record or in Resident #103's Minimum Data Set (MDS) assessments and no further information regarding behavioral issues was provided prior to the end of the survey. Therefore, there was no information available to suggest that a GDR of [MEDICATION NAME] would have been clinically contraindicated for Resident #103. b) Resident #73 Review of the facility's Consultation Report written by the facility's Consultant Registered Pharmacist (RPh) and signed by the Physician and Director of Nursing (DON) on 02/05/19 and 02/08/19, respectively, showed that on 02/04/19 the RPh wrote that Resident #73's [MEDICATION NAME] and [MEDICATION NAME] are due for a gradual dose reduction (GDR) review. The Physician accepted the RPh's recommendation with the following modification(s): , Decrease [MEDICATION NAME] to 5 milligrams (mg) by mouth (po) three times daily (tid) . After the document was signed, by both the Physician and the DON, the [MEDICATION NAME] 10mg, which is a [MEDICAL CONDITION] medication, continued to be administered to the Resident three (3) times daily by the Facility Staff. Also the facility's RPh failed to recognize the prescription error when reviewing the Medication Regimen Review (MRR) each month which resulted in the Resident continuing to receive twice the amount of [MEDICAL CONDITION] medication. Thus, the federal guideline for [MEDICAL CONDITION] medication GDR was not implemented. On 07/01/19 at 2:03 PM, the Surveyor and current DON observed the Resident's medication, located in the Medcart, and found the [MEDICATION NAME] prescription label read [MEDICATION NAME] 10 mg Give 1 tablet by mouth 3 times daily for anxiety.",2020-09-01
870,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,761,E,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and medical record review, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. Four (4) of seven (7) opened insulin pens located in the 200 hallway medication cart were not labeled with the dates the pens were opened. Resident identifiers: #46, #58, #86, and #36. Facility census: 117. Findings included: a) Facility task - medication storage and labeling On 06/26/19 at 9:13 AM, during inspection of the 200 hallway medication cart, four (4) of seven (7) insulin pens were noted to not be labeled with the dates the pens were opened. Specifically, the insulin pens were as follows: - [MEDICATION NAME]pen for Resident #46 - [MEDICATION NAME]pen for Resident #58 - [MEDICATION NAME] Flextouch insulin pen for Resident #86 - [MEDICATION NAME]pen for Resident #36 Licensed Practical Nurse (LPN) #29 confirmed the afore-mentioned insulin pens were not labeled with their opening dates. On 06/26/19 at 9:32 AM, the Administrator was notified four (4) insulin pens in the 200 hallway medication cart were not labeled when opened. She stated she would have these pens removed.",2020-09-01
871,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,791,D,0,1,LUON11,"**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 ensure the necessary dental services were secured for a resident with broken teeth. This deficient practice was found for one (1) of three (3) residents reviewed for the dental care area. Resident identifier: #62. Facility census: 117. Findings included: a) Resident #62 On 06/24/19 at 12:16 PM, Resident #62 stated that one of her bottom teeth was bleeding. Upon observation, it was noted that Resident #62 was missing several of her top row of teeth. Resident #62 stated that she could not remember the last time she had been evaluated by a dentist. Record review during the survey found that Resident #62 was admitted to the facility on [DATE]. On 06/26/19 at 12:57 PM, the only document provided by the facility regarding Resident #62's dental care was reviewed. The document, a consultation report dated 08/08/18, stated, Pt. (patient) needs deep cleaning with curettage (a surgical procedure performed by a dentist, typically under anesthesia), also severed teeth and broken off roots need to be [MEDICATION NAME] down. On 06/26/19 at 3:10 PM, the facility's Director of Nursing (DoN) was asked to provide documentation that the necessary dental work written in the above consult was completed for Resident #62. At 4:56 PM, the DoN stated that this information could not be obtained because the dental office where Resident #62 was a patient was closed. No further information was provided prior to the end of the survey.",2020-09-01
872,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,802,E,0,1,LUON11,"Based on anonymous resident interviews, staff interview, observation, policy review, review of state regulations, and review of the facility's meal schedule the facility failed to ensure it had sufficient dietary staff available to serve meals to residents at a safe and palatable temperature and in a timely manner. 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: 117. Findings included: a) Anonymous Resident Interview During the survey, a resident stated that the facility food looked like vomit and was cold. b) Anonymous Resident Interview During the survey, a resident stated that the facility food was always cold. c) Anonymous Resident Interview During the survey, a resident stated that the facility coffee and food were not hot. d) Anonymous Resident Interview During the survey, a resident stated that their food was not hot upon receipt. e) Anonymous Resident Interview During the survey, a resident stated that the facility food was terrible. f) Anonymous Resident Interview During the survey, a resident tearfully stated that the facility food was nasty. The resident added that they would like to be knocked out before the food comes out because they were forced to watch everyone around them, including their roommate, eat their food before they were given the opportunity to eat their own food. This resident stated that they wanted their food to be hot and they wanted to receive it at the same time as the other residents. e) Anonymous Resident Interview During the survey, a resident described the facility food as sorry. This resident stated that the food was always cold and that the eggs were ice cold. f) Anonymous Resident Interview During the survey, a resident described the facility food as terrible, saying it was cold and inedible. g) Anonymous Resident Interview During the survey, a resident stated that the food was sometimes cold. They added that the food tasted bad and was sometimes inedible because it was either too hard or just nasty. h) Test Tray On 06/27/19 at 8:14 AM, a cart full of breakfast trays was delivered to the 300-hall of the facility. At 8:17 AM, after just a few trays had been passed to residents, it was requested of staff that the next tray to be passed become a test tray and that a new tray be brought out for the resident whose tray was to be tested . At 8:19 AM, Dietary Manager (DM) #121 arrived with a thermometer to test the tray. The tray contained a covered, insulated bowl of oatmeal as well as pancakes and chopped meat covered with gravy. On 06/27/19 at 8:20 AM, the oatmeal was 110 degrees Fahrenheit, the pancakes were 90 degrees Fahrenheit, and the chopped meat covered with gravy was 100 degrees Fahrenheit. DM #121 stated that hot foods should be 140 degrees Fahrenheit at the time of receipt by the resident. On 06/27/19 at 8:24 AM, Regional DM #129 said that he believed there was not a specific temperature requirement for hot foods upon receipt by the resident and that the food was simply to be palatable. At that time, a copy of the facility's food temperature policy was requested. On 06/27/19 at 9:29 AM, Regional DM #129 provided the policy for review. Upon review, the policy, titled Food Handling specified neither the temperature nor the palatability of foods upon receipt by residents, though it did mention that, All Time/Temperature Control for Safety Food must maintain an internal temperature of .135 (degrees Fahrenheit) or higher while being held for service. A review of West Virginia's state nursing home regulations during the survey found that hot foods are to be served to residents at a temperature of no less than 120 degrees Fahrenheit. The above information was discussed with the facility's Administrator on 06/27/19 at 12:07 PM. No further information was provided prior to the end of the survey. i) Meal Delivery Times During the survey, anonymous resident interviews revealed that meal delivery times were inconsistent and unreliable. A review of the facility's Meal Delivery Times schedule during the survey revealed that breakfast was to be delivered daily at 7:20 AM, lunch was to be delivered daily at 12:15 PM, and dinner was to be delivered daily at 5:15 PM. A disclaimer at the bottom of the schedule stated that meal times were approximate and may vary by a few minutes. An observation of the lunch time meal service on 06/26/19 began at 12:12 PM and concluded at 1:33 PM. At 12:12 PM there was not yet food in the main dining room, though there were numerous residents sitting at tables awaiting lunch. At 12:25 PM a drink cart was brought into the main dining room from the kitchen, but no food had been brought out yet. By 12:32 PM multiple residents had left the main dining room without receiving food. At 12:38 PM the first tray came out in the main dining room. At 1:06 PM the 400-hall's trays arrived on a cart along with a drink cart. At 1:28 PM it was observed that a medication pass had begun on the 300-hall, meaning that some residents would receive lunch and medications very close together if the trays arrived soon. At 1:33 PM Dietary Manager (DM) #121 arrived on the 300-hall with a meal cart. When asked why the cart was not delivered at 12:15 PM as scheduled, he stated that only the main dining room had to be served at 12:15 PM. He stated that there was another meal delivery schedule with different times for each unit that had not been shared with surveyors. A copy of the second meal delivery schedule was requested at that time and was never received. On 06/26/19 at 3:10 PM the facility's Director of Nursing (DoN) and Clinical Quality Specialist (CQS) #118 agreed that the late meal delivery and delivering meals during a medication pass on the 300-hall were both problems. On 06/27/19 at 12:07 PM the above information was discussed with the facility's Administrator. She stated that the facility had a second meal delivery schedule with different times that the facility did not share with the public. A copy of this schedule was requested from the Administrator at that time and was never received. No further information was provided prior to the end of the survey.",2020-09-01
873,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,804,E,0,1,LUON11,"Based on anonymous resident interviews, staff interview, observation, policy review, and state regulation review, the facility failed to serve food to residents at a safe and palatable temperature. 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: 117. Findings included: a) Anonymous Resident Interview During the survey, a resident stated that the facility food looked like vomit and was cold. b) Anonymous Resident Interview During the survey, a resident stated that the facility food was always cold. c) Anonymous Resident Interview During the survey, a resident stated that the facility coffee and food were not hot. d) Anonymous Resident Interview During the survey, a resident stated that their food was not hot upon receipt. e) Anonymous Resident Interview During the survey, a resident stated that the facility food was terrible. f) Anonymous Resident Interview During the survey, a resident tearfully stated that the facility food was nasty. The resident added that they would like to be knocked out before the food comes out because they were forced to watch everyone around them, including their roommate, eat their food before they were given the opportunity to eat their own food. This resident stated that they wanted their food to be hot and they wanted to receive it at the same time as the other residents. e) Anonymous Resident Interview During the survey, a resident described the facility food as sorry. This resident stated that the food was always cold and that the eggs were ice cold. f) Anonymous Resident Interview During the survey, a resident described the facility food as terrible, saying it was cold and inedible. g) Anonymous Resident Interview During the survey, a resident stated that the food was sometimes cold. They added that the food tasted bad and was sometimes inedible because it was either too hard or just nasty. h) Test Tray On 06/27/19 at 8:14 AM, a cart full of breakfast trays was delivered to the 300-hall of the facility. At 8:17 AM, after just a few trays had been passed to residents, it was requested of staff that the next tray to be passed become a test tray and that a new tray be brought out for the resident whose tray was to be tested . At 8:19 AM, Dietary Manager (DM) #121 arrived with a thermometer to test the tray. The tray contained a covered, insulated bowl of oatmeal as well as pancakes and chopped meat covered with gravy. On 06/27/19 at 8:20 AM, the oatmeal was 110 degrees Fahrenheit, the pancakes were 90 degrees Fahrenheit, and the chopped meat covered with gravy was 100 degrees Fahrenheit. DM #121 stated that hot foods should be 140 degrees Fahrenheit at the time of receipt by the resident. On 06/27/19 at 8:24 AM, Regional DM #129 said that he believed there was not a specific temperature requirement for hot foods upon receipt by the resident and that the food was simply to be palatable. At that time, a copy of the facility's food temperature policy was requested. On 06/27/19 at 9:29 AM, Regional DM #129 provided the policy for review. Upon review, the policy, titled Food Handling specified neither the temperature nor the palatability of foods upon receipt by residents, though it did mention that, All Time/Temperature Control for Safety Food must maintain an internal temperature of .135 (degrees Fahrenheit) or higher while being held for service. A review of West Virginia's state nursing home regulations during the survey found that hot foods are to be served to residents at a temperature of no less than 120 degrees Fahrenheit. The above information was discussed with the facility's Administrator on 06/27/19 at 12:07 PM. No further information was provided prior to the end of the survey.",2020-09-01
874,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,809,E,0,1,LUON11,"Based on resident interview, staff interview, observation, and record review the facility failed to serve meals and snacks at a time consistent with regular meal times in the community. This deficient practice was found during a random opportunity for discovery and had the potential to affect more than an isolated number of residents. Resident identifiers: #107, #11, #20, #18, #55, #4, #56. Facility census: 117. Findings included: a) Meal Delivery During the survey, anonymous resident interviews revealed that meal delivery times were inconsistent and unreliable. A review of the facility's Meal Delivery Times schedule during the survey revealed that breakfast was to be delivered daily at 7:20 AM, lunch was to be delivered daily at 12:15 PM, and dinner was to be delivered daily at 5:15 PM. A disclaimer at the bottom of the schedule stated that meal times were approximate and may vary by a few minutes. An observation of the lunch time meal service on 06/26/19 began at 12:12 PM and concluded at 1:33 PM. At 12:12 PM there was not yet food in the main dining room, though there were numerous residents sitting at tables awaiting lunch. At 12:25 PM a drink cart was brought into the main dining room from the kitchen, but no food had been brought out yet. By 12:32 PM multiple residents had left the main dining room without receiving food. At 12:38 PM the first tray came out in the main dining room. At 1:06 PM the 400-hall's trays arrived on a cart along with a drink cart. At 1:28 PM it was observed that a medication pass had begun on the 300-hall, meaning that some residents would receive lunch and medications very close together if the trays arrived soon. At 1:33 PM Dietary Manager (DM) #121 arrived on the 300-hall with a meal cart. When asked why the cart was not delivered at 12:15 PM as scheduled, he stated that only the main dining room had to be served at 12:15 PM. He stated that there was another meal delivery schedule with different times for each unit that had not been shared with surveyors. A copy of the second meal delivery schedule was requested at that time and was never received. On 06/26/19 at 3:10 PM the facility's Director of Nursing (DoN) and Clinical Quality Specialist (CQS) #118 agreed that the late meal delivery and delivering meals during a medication pass on the 300-hall were both problems. On 06/27/19 at 12:07 PM the above information was discussed with the facility's Administrator. She stated that the facility had a second meal delivery schedule with different times that the facility did not share with the public. A copy of this schedule was requested from the Administrator at that time and was never received. No further information was provided prior to the end of the survey. b) Evening Snacks Observations on the Night of 06/30/19 found the 8:00 p.m. snacks for Resident #107, Resident #11, Resident #20, Resident #18, Resident #55, Resident #4, and Resident #56 arrived to the nursing unit at 10:10 p.m. At 11:25 p.m. on 06/30/19 the snacks were still sitting on the nurses station counter. The Human Resources Director confirmed the snacks were still sitting on the nurses station counter at 11:25 p.m. on 06/30/19 and had not been distributed to the residents. On 07/01/19 at 2:15 p.m. the Certified Dietary Manager and the Regional Dietary Manager was interviewed and confirmed the snacks labeled with the residents names are to be served at 8:00 p.m.",2020-09-01
875,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,812,E,0,1,LUON11,"Based on observation, staff interview, and policy review, the facility failed to handle food and maintain equipment in a safe and sanitary manner. Equipment in the main kitchen was filthy, nourishment rooms had incomplete refrigerator temperature logs, outdated food was found in the kitchen, food was handled inappropriately by staff in the main dining room, and ice for residents was pre-poured and left uncovered on the 400-hall. These deficient practices were found during random opportunities for discovery and had the potential to affect more than an isolated number of residents. Resident identifier: #105. Facility census: 117. Findings included: a) Kitchen and Nourishment Rooms On 06/24/19 at 10:36 AM an initial tour of the facility's main kitchen began with Dietary Manager (DM) #121. The tour included both the facility's main kitchen and its two (2) resident nourishment rooms. The tour concluded at 11:11 AM. At 10:42 AM an open bottle of poultry seasoning in the dry storage area was found to have a written use by date of 06/03/19. At the time of the finding, DM #121 stated that he did not feel the seasoning had been used, even though it was open. When asked why it had a use by date written on it if it had never been used, DM #121 stated, I have no idea. I'll get rid of it. At 10:45 AM the inside of the kitchen's microwave was found to be splattered with congealed food. At 10:46 AM the juice machine was found to be splattered with juice above the nozzles and the nozzles were found to be covered in dried juice. The coffee machine was also found to have dried coffee running down the front as well as dried coffee on the nozzles. In response to these findings, DM #121 began cleaning kitchen equipment. At 10:48 AM eight (8) food carts used for meal service to residents were found in the kitchen. The carts were found to be dirty with food residue both inside and out as well as garbage inside some of them. This finding was shared with both DM #121 and Regional DM #129. They acknowledged that the carts were filthy and stated that the carts would be cleaned before they were used for lunch service. At 11:05 AM the refrigerator in the nourishment room on the Dogwood unit had a temperature log that was blank for the following dates: -06/19/19 -06/20/19 -06/21/19 -06/22/19 -06/23/19 At the time of the finding, Regional DM #129 stated that the above dates should not have been blank on the log and should have contained refrigerator temperatures. At 11:07 AM the refrigerator in the nourishment room on the Maple unit had a temperature log that was blank on the following dates: -06/01/19 -06/02/19 -06/09/19 -06/16/19 -06/21/19 -06/23/19 At the time of the finding, Regional DM #129 acknowledged that the temperature log should have been filled out with refrigerator temperatures on the above dates. b) Observation of the Main Dining Room An observation of the lunch meal in the main dining room began on 06/24/19 at 12:37 PM. At 12:38 PM, Registered Nurse (RN) #23 touched Resident #105's sandwich with her bare hands. When asked if this was an appropriate way to handle resident food, RN #23 acknowledged that it was not appropriate, but added that she had at least used hand sanitizer first. Regional DM #129 was made aware of the dining observation on 06/25/19 at 9:26 AM, and at that time a copy of the facility's food handling policy was requested. At 9:35 AM, a review of the facility's food handling policy, last revised on 08/08/18, revealed that no bare hand contact with food is allowed and, Antimicrobial gel (hand sanitizer) is not used in the foodservice setting. c) 400 Hallway Observation on 06/24/19 at 1:10 pm, found seven (7) glasses of ice had been poured into glasses and left uncovered and unattended. Interview with Employee #40, nursing assistant (NA) and Employee #89, licensed practical nurse (LPN) confirmed the ice had been pre-poured and left uncovered and unattended.",2020-09-01
876,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,842,E,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** , Based on record review, resident interview and staff interview the facility failed to ensure that each residents record was complete and accurate. Resident #56's record was inaccurate in regards to location his blood pressure was obtained. For resident #78 the facility failed to document in the record about the residents fall. And for Resident #211 the facility did not complete Activities of Daily Living Documentation for multiple days after their admission to the facility. This was true for three (3) for 41 sampled residents. Resident Identifiers: #56, #78, and #211. Facility Census: 117. Findings Include: a) Resident #56 A review of Residents #56 medical record beginning at 3:11 p.m. on 07/01/19 found Resident #56 has an AV Fistula to his left arm and a physicians order for no blood pressures to be obtained in the left arm. An review of Resident #56's recorded blood pressures in the electronic medical record from 04/01/19 through present found on the following the facility documented Resident #56's blood pressure was obtained in his left arm: 04/01/19 at 8:31 p.m. 04/02/19 at 1:04 p.m. 04/03/19 at 8:27 p.m. 04/04/19 at 9:30 a.m. and 1:04 p.m. 04/05/19 at 4:12 p.m. 04/06/19 at 1:18 p.m. 04/07/19 at 1:13 p.m. 04/09/19 at 6:10 a.m. 04/18/19 at 8:41 p.m. 04/19/19 at 9:12 a.m. 04/20/19 at 2:20 p.m. 04/23/19 at 1:45 p.m. 04/25/19 at 5:03 p.m. 04/26/19 at 5:36 p.m. 04/27/19 at 3:18 p.m. 04/28/19 at 3:26 p.m. 04/30/19 at 3:05 p.m. and 8:32 p.m. 05/01/19 at 8:07 p.m. 05/02/19 at 8:14 p.m. 05/04/19 at 1:16 p.m. 05/07/19 at 8:41 p.m. 05/09/19 at 8:20 p.m. 05/13/19 at 9:46 a.m. 05/14/19 at 10:11 a.m. and 8:35 p.m. 05/17/19 at 8:09 p.m. 05/19/19 at 10:30 a.m. 05/21/19 at 8:11 p.m. 05/28/19 at 5:19 p.m. 05/31/19 at 7:31 a.m. 06/02/19 at 8:53 p.m. 06/03/19 at 8:46 p.m. 06/04/19 at 8:34 p.m. 06/07/19 at 9:13 a.m. 06/08/19 at 5:50 a.m. and 9:08 a.m. 06/22/19 at 5:30 a.m. and 10:25 p.m. 06/28/19 6:01 a.m. 06/30/19 at 12:35 a.m. An interview with Resident #56 at 9:30 a.m. on 06/25/19 revealed he does not allow them to take his blood pressure in his left arm. He stated, If they try that I stop them. They only take my blood pressure in my right arm. An interview with the Director of Nursing at 2:40 p.m. on 07/01/19 confirmed the blood pressure documentation as to where the blood pressure was obtained was inaccurate on the above named dates and times. b) Resident #211 Review of Resident #211's medical records found the resident was admitted to the facility on [DATE]. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found no documentation until 06/23/19. (5 days later) On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident had no documentation existed until 06/23/19 to indicate the ADLs were provided until five days after admission. No further information provided.",2020-09-01
877,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,867,E,0,1,LUON11,"Based on record review, resident interview, staff interview and policy review, the Quality Assurance and Assessment (QA&A) committee failed to identify deficient practices of which they should have been aware of. The facility failed to ensure residents were free from abuse and neglect. The facility failed to ensure allegations of abuse/neglect were reported to the proper state agencies. The facility failed to ensure the required information was sent with residents at the time of discharge/transfer. The facility failed to ensure activities of daily living (ADL) care was provided. The facility failed to ensure residents were provided restorative therapy. The facility failed to ensure residents maintained proper nutrition. The facility failed to ensure sufficient staff with appropriate skill sets were available. The facility failed to ensure sufficient dietary staff were available. This practice has the potential to effect more than an isolated number of residents. Facility census: 117. Findings include: a) Cross reference deficiency findings at F660 b) Cross reference deficiency findings at F609 c) Cross reference deficiency findings at F623 e) Cross reference deficiency findings at F677 f) Cross reference deficiency findings at F688 g) Cross reference deficiency findings at F692 h) Cross reference deficiency findings at F725 i) Cross reference deficiency findings at F802 j) Interviews On 07/01/19 at 1:01 PM, the director of nursing (DON) was interviewed regarding the above deficient practices as the administrator was not available. At 4:42 PM on 07/01/19, the DON and the registered nurse corporate consultant returned and said they could find no verification that any of the above deficient practices were discussed in QA&A meetings.",2020-09-01
878,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,880,E,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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. This had the potential to affect a limited number of residents. this was a random opportunity for discovery. Identified Resident #94 and #6 as well as the shower room on the 200 hall and the 300 hall. Facility census 117. Findings included: a) Resident # 94 During an observation of wound care on 06/26/19 at 9:46 AM, it was noted that Nurse Aide (NA) #59 left the room and did not wash her hands even after being reminded by Registered Nurse #28 to do so. On 06/26/19 at 10:02 AM, NA #59 return to residents' room with a pillow. She and RN #28 was asked if she should have washed her hands after she removed her gloves. NA #59 stated, that she should have and just got in a hurry. They agreed this was an infections control breech. b) Resident #6 During an observation of catheter care on 07/01/19 at 9:58 AM, Nurse Aide (NA) #38, failed to use a barrier on the floor while emptying the Foley catheter bag. She also failed to wipe the tip of the drainage spout before inserting into the protective sleeve. After the care was completed NA #38 stated, that she was unaware that, she should have used a barrier and wiped the tip of the drainage spout. On 07/01/19 at 10:07 AM, Director of Nursing was informed of observations. She had no comments. c) Shower room on the 200 hall On 06/30/19 at 9:50 PM, Licensed Practical Nurse (LPN) #71 verified that in the shower room on the 200 hall had dries fecal matter on the floor and it had been walked in. She stated, that she has no idea how long that had been there, because on one received a shower today. She stated, that housekeeping left at 2:30 PM, today. On 07/01/19 at 8:45 AM, Account Manager of housekeeping was asked if the shower floor on the 200 hall was cleaned on 06/29/19 and 06/30/19. She stated, that it should have. When she was informed about the finding of dried fecal matter on the floor she stated, that that would have been the responsibility of the nurse aide to clean up any body fluids. She also said, that her staff should have sanitized the shower room. . d) 300 Hallway - Floor On 07/01/19 at 1:23 PM, observation was made of a dark brown smashed gooey substance that appeared to be fecal matter in the floor in front of the nurse's station on 300 hall. The brown fecal-like matter had been stepped in and spread down hallway with in a trail that ended at the doorway of Resident room [ROOM NUMBER]. At 1:24 PM on 07/01/19 the gooey, dark brown substance that appeared to be feces smeared in the floor (of the 300 hallway) was brought to the attention of charge nurse Licensed Practical Nurse (LPN) #51. After inspection of the gooey brown spots on floor, LPN #51 cleaned up the substance with bleach wipes and stated, It does appear to be stool (a piece of feces).",2020-09-01
892,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2017-03-15,164,D,0,1,X99F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and observation, the facility failed to ensure a medication and pharmacy labels were disposed of in a manner to protect personal, medical, and health information. Personal identifiers including a resident's name and medication were listed on the pharmacy label. This was a random observation. Resident identifier: #13. Facility census: 100. Findings include: a) A random observation of the 200 Hall, on 03/14/17 at 8:45 a.m., revealed one (1) visible empty medication card/packet in the trash can of the medication cart. The following medication card contained the resident's full name and medication order for [MEDICATION NAME] 25 milligrams (mg) on the pharmacy label. An interview with Licensed Practical Nurse (LPN) #1, on 03/14/17 at 8:50 a.m., revealed they only remove the resident's information from discarded medication packets for narcotic medications. The LPN stated all other medication packets are just thrown in the trash. An interview with the Director of Nursing (DON), on 03/14/17 at 11:00 a.m., revealed all empty medication cards/packets should have the resident's information removed before discarding.",2020-09-01
893,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2017-03-15,253,E,0,1,X99F11,"Based on observation and resident interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This failed practice included: missing, cracked, stained and discolored floor tile; scratched and marred interior and exterior doors; scraped areas in a bathroom; multiple scratches and missing paint in a resident room; closet exterior door with mismatched paint; chipped and missing veneer on furniture with exposed particle board; a trash can push top with rusted and peeling paint with rough opening and edges; and cracked and uneven rubber tile in hallways; soiled and stained wallpaper in hallways. This practice has the potential to affect more than a limited number of residents. Room identifiers: #210, #313, #402, #404, #405, #409, #410, #411, #413, #504, #517 and #603. Facility census: 100. Findings include: a) On 03/15/17 between 9:20 a.m. to 9:45 a.m., accompanied by Dietary Manager (DM) #124 and Maintenance Helper #30, a tour of the facility revealed the following environmental concerns/cosmetic imperfections: 1. Observation of Room #210 found: --Multiple scratches and paint missing on the wall beside the bed. 2. Observation of Rooms #313, #402, #404, #410, #411 and #413 found: --Stained and discolored floor tile in hallway near Resident exterior entrance door and at the entrance door threshold. 3. Observation of Room #405 found: --Scratched and marred areas on the interior and exterior of the bathroom door --A closet exterior door in the resident room had a 12 inch by 6 inch repaired area that does not match door paint. --Stained and discolored floor tile in hallway near Resident exterior entrance door and at the entrance door threshold. 4. Observation of Room #409 found: --Stained and discolored floor tile in hallway near Resident exterior entrance door and at the entrance door threshold. --Large scraped areas on the left side and the back bathroom wall. 5. Observation of Room #504 found: --Chipped veneer on lower third closet door edge and upper and lower edge of desk edge. 6. Observation of Room #517 found: --Stained and discolored floor tile in hallway near Resident exterior entrance door and at the entrance door threshold. --Desk veneer corner chipped off exposing particle board. 7. Observation of Room #603 found: --Bedside table chipped along top front edge in multiple places, exposing inner particle board. 8. Observation of the 300 hallway found: --Main hallway had cracked and missing floor tile surrounding the two (2) floor drains in the middle of the hallway. 9. Observation of the 500 hall resident common bathroom found: --A trash can with rusted, chipped and peeling paint by the push opening, which is rough around opening and edge where lid comes off. 10. Observation of the 600 hall resident shower room found: --Cracked and chipped rubber floor tile in front of shower stall. 11. Observation of the 600 hallway found: --Cracked and uneven rubber floor tile in two (2) sections of the hallways. --Soiled and stained textured wall paper/covering from floor to handrails throughout a hallway and half (1/2) way up from the floor in some areas. b) At the conclusion of the tour both DM #124 and Maintenance Helper #30 agreed the observed concerns needed either repaired and/or replaced.",2020-09-01
894,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2017-03-15,323,E,0,1,X99F11,"Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which the facility had control. The 500 and 600 Hall Shower Rooms, which contained chemical substances, were unlocked and the 400 and 500 hallways had rough handrails. This practice had the potential to affect more than a limited number of residents. Facility census: 100. Findings include: a) 500 Hall Shower Room A random observation, on 03/13/17 at 1:00 p.m., revealed the 500 Hall Shower Room was unlocked. The room contained the following items: --One (1) bottle of Afta aftershave and skin conditioner with the warning, Keep out of reach of children. Avoid contact with eyes. --One (1) bottle of Intimate Secret body mist with the warning, Keep out of reach of children. Avoid contact with eyes. --One (1) container of McKesson baby powder with the warning, Keep out of reach of children. Avoid contact with eyes. Do not use on broken skin. --One (1) container of Medicated Bismoline Powder with the warning, Keep out of reach of children. In case of accidental ingestion seek professional assistance or contact a Poison Control Center immediately. --One (1) container of McKesson shaving cream with the warning, Keep out of reach of children. --One (1) container of GOJO body and hair shampoo with the warning, Caution-Keep out of eyes. If swallowed contact a physician or a Poison Control Center immediately. b) 600 Hall Shower Room A random observation, on 03/13/17 at 1:10 p.m., revealed the 600 Hall Shower Room was unlocked. The room contained the following items: --One (1) container of GOJO body and hair shampoo with the warning, Caution-Keep out of eyes. If swallowed contact a physician or a Poison Control Center immediately. --One (1) container of McKesson shaving cream with the warning, Keep out of reach of children. --One (1) container of McKesson baby powder with the warning, Keep out of reach of children. Avoid contact with eyes. Do not use on broken skin. An interview with Licensed Practical Nurse (LPN) #24 on 03/13/17 at 1:15 p.m. revealed the 500 and 600 hall shower rooms do not have locks on them. The LPN stated all chemical substances should be locked up. c) Rough Handrails During a tour accompanied by Dietary Manager (DM) #124 and Maintenance Helper #30, on 03/15/17 between 9:20 a.m. to 9:45 a.m., the following issues/concerns were observed. --The corridor handrails in the main hallways utilized by residents as a main thoroughfare, were found to have been improperly repaired with a clear/tan colored glue like substance that was rough to the touch. This was found in the hallways outside of rooms: #304, #405, #510, #514, #516, #517, outside of a door labeled nursing supply on the 500 hall, and outside of a door labeled soiled utility. At the conclusion of the tour both DM #124 and Maintenance Helper #30 agreed the identified concerns needed either repaired and/or replaced, and did pose an accident hazard for residents getting injured on the rough material. .",2020-09-01
895,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2017-03-15,371,E,0,1,X99F11,"Based on observation and staff interview, the facility failed to prepare and store food under safe and sanitary conditions. An employee failed to sanitize her hands during meal service after picking up an item off the floor. In addition, an ice machine drain was incorrectly installed, lacking an air gap to prevent back flow from back-siphon or back-pressure. This has the potential to affect more than a limited number of residents. Facility census: 100. Findings include: a) During a dining observation, on 03/13/17 at 12:26 p.m., of the lunch meal trays being assembled in the main dining room for individual distribution to residents, Nurse Aide (NA) #80 was assembling the meal trays received from the kitchen with meal tickets and drinks. NA #80 failed to wash or sanitize her hands after picking a clothing protector off the floor and proceeded to continue to assemble resident trays. NA #80 stated in an interview immediately following this observation, No I didn't sanitize or wash my hands after picking the clothing protector off the floor. b) Ice Machine An observation of the facility ice machine on the 500-600 hall, on 03/13/17 at 10:13 a.m., revealed the ice machine drainage pipe lying on the floor, with the end of the pipe hanging down into the sewer drain, below the floor level and in direct contact of the side of the sewer drain. Small particles of black debris were noted around the end of the ice machine discharge pipe and between the ice machine drainage pipe and the sewer drain pipe. During an interview, on 03/14/17 at 9:45 a.m., the Director of Nursing (DON) reported she was unaware the ice machine was connected incorrectly and was unaware of any guidelines related to how the ice machine drip line should not be directly connected to the drain to prevent back-flow and contamination. During a follow up interview on 03/14/17, the DON reported the ice machine drain had been repaired. A follow up observation, on 03/15/17 at 9:07 a.m., verified the ice machine drain was now physically separated from the floor/sewage drain. b) Ice Machine An observation of the facility ice machine on the 500-600 hall, on 03/13/17 at 10:13 a.m., revealed the ice machine drainage pipe lying on the floor, with the end of the pipe hanging down into the sewer drain, below the floor level and in direct contact of the side of the sewer drain. Small particles of black debris were noted around the end of the ice machine discharge pipe and between the ice machine drainage pipe and the sewer drain pipe. During an interview, on 03/14/17 at 9:45 a.m., the Director of Nursing (DON) reported she was unaware the ice machine was connected incorrectly and was unaware of any guidelines related to how the ice machine drip line should not be directly connected to the drain to prevent back-flow and contamination. During a follow up interview on 03/14/17, the DON reported the ice machine drain had been repaired. A follow up observation, on 03/15/17 at 9:07 a.m., verified the ice machine drain was now physically separated from the floor/sewage drain.",2020-09-01
896,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2017-03-15,441,E,0,1,X99F11,"Based on observation and interview the facility failed to provide a sanitary environment to prevent the development and transmission of disease and infection. An employee conducting medication administration did not wash or sanitize their hands after each resident encounter. Resident #49 had a chair in their room that was torn and exposing the cushion. This practice affected more than a limited number of residents. Resident identifiers: #21, #49, #115, #120, and #135. Facility census: 100. Findings include: a) Handwashing An observation of medication administration, on 03/15/17 from 8:15 a.m. to 8:45 a.m., revealed Licensed Practical Nurse (LPN) #21 did not wash or sanitize her hands after each resident encounter. Resident #21, #115, #120, and #135 were given medications during this time. An interview with LPN #21, on 03/15/17 at 8:45 a.m., revealed she forgot to wash her hands during the medication administration because she was nervous. LPN #21 stated she should always wash or use hand sanitizer after each resident during medication administration. An interview with the Director of Nursing, on 03/15/17 at 10:30 a.m., revealed all nursing staff should wash or sanitize their hands after each resident during medication administration. b) Chair An observation, on 03/13/17 at 11:00 a.m., found the seat cushion of a large blue chair in Resident #49's room was torn exposing the chair filling. A large deep slit, approximately 6 inches long was noted in the center of the seat running from the front seat edge towards the back of the chair. Maintenance helpers #130 and #121 agreed the chair cushion needed to be repaired during an interview on 03/13/17 at 12:45 p.m. They reported they routinely make rounds assessing the environment, but the nursing staff need to fill out a slip request for the repair. The maintenance helpers agreed the chair could not be sanitized and removed it immediately. The infection interventionist Registered Nurse #78, confirmed the torn chair cushion was an infection concern during an interview on 03/14/17 at 2:00 p.m.",2020-09-01
897,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2017-03-15,456,D,0,1,X99F11,"Based on observation and staff interview, the facility failed to ensure resident equipment and chairs were maintained in a safe comfortable operating condition. A chair in a resident's room utilized by the resident and visitors had a large deep tear in the seat cushion. This has the potential to affect more than a limited number of residents. Resident #49. Facility census: 100. Findings include: a) Chair An observation on 03/13/17 at 11:00 a.m., found the seat cushion of a large blue chair in Resident #49's room was torn exposing the chair filling. A large deep slit, approximately 6 inches long was noted in the center of the seat running from the front seat edge towards the back of the chair. Maintenance helpers #130 and #121 agreed the chair cushion needed to be repaired during an interview on 03/13/17 at 12:45 p.m. They reported they routinely make rounds assessing the environment, but the nursing staff need to fill out a slip request for the repair. The maintenance helpers agreed the chair could not be sanitized, should not be used by a resident and removed it immediately.",2020-09-01
898,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2017-03-15,514,D,0,1,X99F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the completeness and accuracy of the clinical record for one (1) of twelve (12) residents reviewed during Stage II of the Quality Indicator Survey. Resident #33's medical record lacked information related to the care and treatment he received, including a discharge summary and plan of care during a recent stay at an acute center. Resident Identifier: #33. Facility census: 100. Findings include: a) Resident #33 Review of the medical record, on 03/15/17 at 10:55 a.m., revealed Resident #33 had two recent stays at acute care centers. He was recently discharged from the hospital and returned to the facility on [DATE]. The computerized nursing observation record, dated 02/16/17 at 04:03 p.m., revealed the resident returned from hospital via an ambulance, and medications and orders were reconciled with physician. The medical record lacks any information related to this recent stay at the hospital including any treatments, testing, or physician's discharge summary. In addition, the records were silent in regards to the Stage II pressure ulcer he developed prior to his transfer to the acute care center on 02/12/16. On 03/15/17 at 11:27 a.m., the medical records supervisor confirmed the chart lacked a discharge summary for Resident #33's recent stay at the acute care center. She contacted the hospital and was told the record could not be released without a physician's signature. Registered Nurse (RN) #78 reviewed the medical record during an interview, on 03/15/17 at 11:30 a.m., and confirmed there was no information related to the resident's recent stay in the acute care center. RN #81 was interviewed, at 11:45 a.m. on 03/16/17, and stated they usually do not get any information from the acute care center related to the resident's treatment, diagnosis, or recent assessments and the hospital rarely addresses the resident's pressure ulcers. Upon return to the facility, the staff nurses do not document in the records any report they receive from the acute care center. RN #81 confirmed Resident #33 still had a Stage II pressure ulcer when he returned to the facility and agreed the chart lacked information related to any treatments or [DIAGNOSES REDACTED]. A copy of the physician's discharge summary was presented to the team at the time of exit. The form lacks any information related to his Stage II pressure ulcer.",2020-09-01
899,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2018-05-02,584,E,0,1,GH3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide a homelike environment during dining and to offer maintenance services in resident rooms. The dining room environment did not offer stimulation such as television, music, activities, or beverage service while the residents waited for their meals. This practice affected more than a limited number of residents. The facility did not provide maintenance services for nine (9) of seventy (70) rooms observed during the Long Term Care Survey Process (LTCSP). The issues identified included resident's rooms and bathrooms with scratched walls and doors, stained floors, a stained ceiling, a hole in a wall, peeling paint, and a damaged resident chair. Room identifiers: #112, #204, #207, #208, #307, #309, #313, #413, and #604. Facility census: 95. Findings included: a) Observations The following observations were made on 04/30/18, 05/01/18, and 05/02/18 during the LTCSP: -room [ROOM NUMBER]-There were multiple scrapes on the walls. -room [ROOM NUMBER]-The door was scratched and marred. -room [ROOM NUMBER]-The ceiling had a dark circular stain. -room [ROOM NUMBER]-The floor was stained black in several areas. -room [ROOM NUMBER]-The seal around the toilet was rusted. -room [ROOM NUMBER]-There was a hole in the wall beside the toilet. -room [ROOM NUMBER]-The paint was peeling off of the bathroom ceiling. -room [ROOM NUMBER]-The walls were marred and the bathroom door was scraped. -room [ROOM NUMBER]-The Geri Chair in the room had frayed arms and one of the pads were loose. An interview with the Maintenance and Housekeeping Supervisor, on 05/02/18 at 11:25 AM, revealed resident room rounds are done weekly. The Supervisor stated she must have missed the issues observed in the rooms but would ensure they would be fixed this week. b) During dining observations in the 300 hallway dining room on 04/30/18 at 12:02 p.m. it was noted the facility did not ensure that residents had a homel ilke environmemt while dining. Approximately 33 residents were present waiting for lunch to be served. There were no table cloths, music, TV or any other type of stimulation going on while the residents waited for the meal. Additionally, no beverages were served or any activity of any type occurred. Trays did not begin arriving in the dining room until 12:30 p.m. During the random observations a male resident was overhead saying where is the food? Wonder what is going on.? He expressed he did not like having to wait so long for the food. After he received his tray, he was asked how the food was and he stated it was good and there was plenty of it, but it took for ever to get it. This was discussed with the DON and ADON on 05/01/18 at 9:15 a.m.",2020-09-01
900,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2018-05-02,657,D,0,1,GH3711,"Based on resident interview, staff interview, and medical record review, the facility failed to ensure Resident #38 was invited to attend and participate in care plan meetings. Resident #38 had not been invited or attended a care plan meeting since (YEAR). This practice affected one (1) of twenty (20) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifier: #38. Facility census: 95. Findings included: a) Resident #38 An interview with Resident #38, on 05/02/18 at 10:00 AM, revealed she had not been invited to or attended a care plan meeting in years. The Resident stated the staff does not discuss any aspect of her care plan with her. A review of the Resident's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/07/18, was conducted on 05/02/18 at 10:15 AM. Section C-Cognitive Patterns of the assessment revealed the Resident scored a 15 on the Brief Interview for Mental Status (BIMS) assessment. A score of 15 indicated the Resident had little to no impairment. A review of the Resident's medical record, on 05/02/18 at 11:00 AM, revealed there was no documentation the Resident had been invited to or attended any care plan meetings. An interview with the Director of Nursing (DON), on 05/02/18 at 11:15 AM, revealed all residents or representatives should be invited to attend all care plan meetings. The DON stated Resident #38 had not been attending care plan meetings. The DON stated she could not provide any documentation where Resident #38 had been invited or attended a care plan meeting since (YEAR).",2020-09-01
901,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2018-05-02,689,E,0,1,GH3711,"**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. Chemical substances and multiple glass vases were unsecured and accessible to residents in the 500 Hall Soiled Utility Room. This practice had the potential to affect more than a limited number of residents. Facility census: 95. Findings included: a) Observations A random observation of the 500 Hall, on 05/02/18 at 7:55 AM, revealed the Soiled Utility Room was locked but had a key hanging beside the door. The Soiled Utility Room contained the following items: -One (1) container of Magic Line Broad Spectrum Disinfectant-Hospital Use with the warning Danger-Poison-Keep out of reach of children-Hazard to humans-Corrosive-Causes eye and skin damage. -One (1) container of Great Value Disinfectant Spray with the warning Caution-Keep out of reach of children-Hazard to humans-Causes moderate eye irritation. -One (1) container of Comet Deodorizing Cleanser with the warning Keep out of reach of children-Causes eye irritation. -One (1) container of Oasis 259 Glass Cleaner with the warning Caution-Keep out of reach of children-Causes eye and skin irritation. -Thirty (30) glass vases of varying shapes and sizes on multiple shelves and in unsecured cabinets. b) Interviews An interview with the Assistant Director of Nursing (ADON), on 05/02/18 at 9:15 AM, revealed all chemical substances should be locked up from all residents. The ADON stated the key hanging beside the door allowed the chemicals and glass vases in the Soiled Utility Room to be accessible to anyone. The ADON stated she would remove the key immediately. An interview with the Director of Nursing (DON), on 05/02/18 at 1:00 PM, revealed the key for the 500 Hall Soiled Utility Room had been hanging by the door for [AGE] years.",2020-09-01
902,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2018-05-02,812,E,0,1,GH3711,"Based on observations and staff interview, the facility failed to maintain equipment in a sanitary manne., Drip pans in the range top and the oven doors were found to be in need of cleaning. Food debris was in the drip pans and the oven had a greasy like substance on then inside and outside of the doors. This practice has the potential to affect more than a limited number of residents who are served foods from this central location. Census: 95. Findings included: a) On 04/30/18 at 11:45 a.m. an initial tour was conducted of the dietary department with Employee #32. The following items were noted: drip pans under the range top were hard to pull out and once were out found to be soiled with lots of food debris and a greasy substance. Also oven doors had lots of food splatters and grease build up, and were in need of cleaning. This practice indicated the equipment had not been maintianed in a sanitary manner.",2020-09-01
903,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2018-05-02,838,F,0,1,GH3711,"Based on staff interview and observation, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Staff confirmed a facility-wide assessment had not been completed. This practice has the potential to affect all residents residing in the facility. Facility census: 95. Findings included: a) On 05/01/18 at 9:42 AM, a request was made to the Director of Nursing a copy of the facility assessment. The DoN stated that the facility did not have or complete a facility assessment. In addition, the DoN stated the facility did not have access to the forms necessary to complete a facility assessment. Per the regulations from the Center for Medicare and Medicaid Services (CMS) the facility was required to complete a facility assessment. This regulation went into effect on 11/28/17.",2020-09-01
904,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2018-05-02,883,E,0,1,GH3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy and procedure review, medical record review and staff interview, the facility failed to assess for prior Prevnar 13 (pneumonia vaccine) vaccination and/or provide the Prevnar 13 according to the Center for Disease Control (CDC) guidelines/recommendations. In addition, the facility infection control policy contained no reference to following CDC guidelines/recommendations for the Prevnar 13 vaccination. This practice affected four (4) of five (5) residents reviewed for flu/pneumonia vaccinations. Resident identifiers: #11, #20, #22 #45. Facility census: 95. Findings included: a) Policy Review Review of the policy statement titled Vaccinations revised on 11/28/16, stated the administration of the pneumococcal ([MEDICATION NAME] 23) vaccination stated all new residents shall be assessed for pneumococcal vaccine status upon admission. Residents shall be offered one (1) dose of [MEDICATION NAME] unless medically contraindicated or the resident has already been vaccinated. No evidence was found regarding the Prevnar 13 pneumonia vaccine. b) CDC recommendations Review of the current CDC recommendations found that the CDC recommends routine administration of pneumococcal conjugate vaccine (Prevnar 13) for all adults [AGE] years or older. CDC recommends that adults [AGE] years or older who have not previously received Prevnar 13, should receive a dose of Prevnar 13 first, followed one (1) year later by a dose of [MEDICATION NAME] 23. If the patient already received one (1) or more doses of [MEDICATION NAME] 23, the dose of Prevnar 13 should be given at least one (1) year after they received the most recent dose of Pneuomovax 23. c) Resident #11 A review of the medical record for Resident #11 revealed an admission date of [DATE], with no assessment and/or offer of the Prevnar 13. d) Resident #20 A review of the medical record for Resident #20 revealed an admission date of [DATE], with no assessment and/or offer of the Prevnar 13. e) Resident #22 A review of the medical record for Resident #22 revealed an admission date of [DATE], with no assessment and/or offer of the Prevnar 13. f) Resident #45 A review of the medical record for Resident #45 revealed an admission date of [DATE], with no assessment and/or offer of the Prevnar 13. f) Interview On 05/01/18 at 1:27 PM per interview with Registered Nurse (RN) #29 stated no resident in the facility had been offered and/or given the Prevnar 13 vaccine. RN #29 further stated that the facility was not aware of the CDC recommendations for giving Prevnar 13. She stated the facility would immediately assess each residents immunization status and give the Prevnar 13 as per CDC recommendations.",2020-09-01
905,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,550,D,0,1,9FZF11,"Based on observation and staff interview, the facility failed to treat each resident with respect and dignity, and in an environment that promoted maintenance or enhancement of his or her quality of life. Multiple residents were seen by a physician at the same time, a resident was wearing only a brief and could be seen from the hallway, a nurse initialed and dated a wound care dressing after it was on the resident, and a catheter bag was not covered. These practices affected more than a limited number of residents. Resident identifiers: #9, #17, and #59. Facility census: 98. Findings included: a) Resident #17 An observation of the 600 Hallway, on 07/08/19 at 10:15 AM, revealed Resident #17 was sitting up in a chair in his room wearing only a t-shirt and a brief. The Resident did not have pants on. The Resident was fully visible from the hallway. The privacy curtain was not closed and the Resident had nothing covering his lower body. An interview with Licensed Practical Nurse (LPN) #125, on 07/08/19 at 10:18 AM, revealed the Resident prefers not to wear pants when he is up in his chair. The LPN stated the Resident should be covered with a blanket or have his privacy curtain closed when wearing only a brief. b) Resident # 9 On 07/10/19 at 11:00 AM registered nurse (RN) #44, completed wound care for Resident #9. Upon completing the care RN #44 placed the bandage on the resident and then placed a date and initial on the bandage. Registered nurse #44 explained she usually dates and initials the bandage before placement but was nervous, due to being monitored, while completing the care.",2020-09-01
906,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,580,D,0,1,9FZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to immediately contact resident's physicians and the resident's representatives when an incident involving residents occurred. Physicians and resident representatives were not contacted immediately when there was an allegation of sexual abuse. This practice affected two (2) of twenty-three (23) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #89 and #252. Facility census: #98. Findings included: a) Policy Review 1. Notification of Changes Facility Policy A review of the facility's policy Notification of Changes with an implementation date of 11/27/17 was reviewed on 07/10/19. The policy stated the facility is to ensure the Center promptly informs the resident, consult's the resident's physician; and notify, consistent with his or her authority, resident representative when there is a change requiring notification. This includes competent individuals. Circumstances requiring notification include a resident's physical, mental, or psychosocial condition. 2. Compliance with Reporting Allegations of Abuse Neglect Exploitation Facility Policy A review of the facility's policy Compliance with Reporting Allegations of Abuse Neglect Exploitation with an implementation date of 11/27/17 was reviewed on 07/10/19. The policy stated The Center is to report all allegations of abuse/neglect/exploitation to the approprpriate agencies in accordance with current state and federal regulations. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. The Licensed Nurse or designee will respond to the needs of the resident and protect him/her from further incident, notify the Director of Nursing and Administrator, notify the attending physician, resident's family, and medical director, monitor and document the resident's condition-including response to medical intervention and nursing interventions, document actions taken in the medical record, and complete an incident report and initiate an investigation. b) Record Review A review of the medical record for Resident #89, on 07/10/19 at 10:45 AM, revealed the Resident was admitted to the facility in (MONTH) of 2019 with the primary [DIAGNOSES REDACTED]. The Resident did not have capacity. The Resident had a healthcare surrogate. A review of the medical record for Resident #252, 07/10/19 at 10:55 AM, revealed the Resident was admitted to the facility in (MONTH) 2019 with fractures sustained from a motorcycle accident. The Resident was fully capacitated. The Resident was discharged from the facility to home 11 days after admission. A review of the Nurses Notes for Resident #89, on 07/10/19 at 11:50 AM, revealed the following note: -06/06/19 at 10:45 AM-Resident #89 inappropriately touched a female resident's breast. The female was Resident #252. Further review of the Nurses Notes for Resident #89, on 07/10/19 at 11:10 AM, revealed the following notes involving other instances of inappropriate sexual behavior with the Resident: --05/13/19 at 1:25 PM-Resident #89 is sexually inappropriate with staff and difficult to redirect. --05/14/19 at 7:25 AM-Resident #89 is combative with care, physically/verbally/sexually inappropriate with staff. --05/15/19 at 7:25 AM-Resident #89 has behaviors, sexual, physical and verbal. Resident is one on one for these behaviors as of right now. --05/16/19 at 7:25 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. --05/18/19 at 7:25 AM-Resident #89 has inappropriate sexual behavior with CNAs and other staff. --05/20/19 at 7:25 AM-Resident #89 makes sexual remarks. --05/23/19 at 7:25 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. --05/29/19 at 11:10 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. --06/09/19 at 8:26 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. The record contained no evidence the physician or legal representative was notified of the inappropriate sexual behaviors exhibited from 05/13/19 through 06/09/19. Further review of the medical record for Resident #89, on 07/10/19 at 11:05 AM, revealed no documentation the the care plan was updated to reflect the inappropriate sexual behaviors exhibited from 05/13/19 through 06/09/19. Further review of the medical records for Resident #89 and #252, on 07/10/19 at 11:05 AM, revealed no documentation the physician was contacted for either resident concerning this incident. The Resident Representative for Resident #89 was also not notified. c) Interviews An interview with the Director of Nursing (DON), on 07/10/19 at 11:15 AM, revealed Resident #252 had reported to the staff that Resident #89 touched her breast inappropriately on 06/06/19. The DON stated she had no documentation that the physician or resident representative had been contacted concerning the incident. The DON verified there was no documentation in Resident #252's record concerning the incident. The DON stated she did not know Resident #252 reporting that her breast was touched inappropriately was an allegation of sexual abuse. The DON stated she had no idea the physician or resident representative had to be contacted for the incident. The DON stated there was no investigation completed and that there were no physician interventions put into place for the allegation on 06/06/19. The DON stated she could not provide any documentation showing that either Resident involved was assessed immediately after the incident occurred. An interview with the Clinical Continuous Quality Coordinator (CCQC), on 07/10/19 at 11:20 AM, revealed the incident on 06/06/19 with Resident #89 and Resident #252 was an allegation of sexual abuse. The CCQC stated the physician and all responsible parties should have been notified immediately upon the report of the allegation. The CCQC stated she had reviewed the records for Resident #89 and Resident #252 and there was no documentation the physician or responsible parties were notified. The CCQC verified there was no documentation in Resident #252's record concerning the incident on 06/06/19. The CCQC also stated all required parties would be notified on 07/10/19. The facility only notified the physician and legal representative after identification of the issue by this surveyor. An interview with the Administrator, on 07/10/19 at 11:30 AM, revealed she could not provide any documentation from 06/06/19 that assessments notification of the physician or resident representative, was done for Resident #89 or Resident #252. An interview with the facility's Medical Director and Physician to Resident #89 and #252, on 07/10/19 at 12:30 PM, revealed he does not remember being contacted about the incident where Resident #89 touched Resident #252's breast. The Medical Director agreed he should have been notified.",2020-09-01
907,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,583,E,0,1,9FZF11,"Based on observation and staff interview, the facility failed to maintain personal privacy for residents. Multiple residents were seen by a physician at the same time and a resident was wearing only a brief and could be seen from the hallway. This practice affected more than a limited number of residents. Resident identifier: #17. Facility census: 98. Findings included: a) Physician visits An observation of the 600 Hallway, on 07/10/19 at 8:30 AM, revealed a Podiatrist was in a room seeing residents. At the time of the observation the Podiatrist was inspecting a resident's foot while six (6) other residents in the room watched. The door was open and anyone could observe from the hallway. Registered Nurse (RN) #44 was in the room at the time of the observation. An interview with RN #44, on 07/10/19 at 8:35 AM, revealed this was a normal practice when the Podiatrist visited the facility. The RN stated the Podiatrist usually sees around thirty residents on his visits. The RN stated she did not agree with the practice of having multiple residents in the room while they are being seen by the physician. The RN stated they do that because management told us that we cannot line the residents up in the hallway when they wait for their time with the doctor. b) Resident #17 An observation of the 600 Hallway, on 07/08/19 at 10:15 AM, revealed the Resident was sitting up in a chair in his room wearing only a t-shirt and a brief. The Resident did not have pants on. The Resident was fully visible from the hallway. The privacy curtain was not closed and the Resident had nothing covering his lower body. An interview with Licensed Practical Nurse (LPN) #125, on 07/08/19 at 10:18 AM, revealed the Resident prefers not to wear pants when he is up in his chair. The LPN stated the Resident should be covered with a blanket or have his privacy curtain closed when wearing only a brief.",2020-09-01
908,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,584,E,0,1,9FZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain the facility in good repair in 10 of 30 rooms, and failed to maintain adequate lighting in all resident areas. This deficient practice had the potential to effect more than a limited number of residents. Room identifiers: 304, 610, 108, 306, 603, 104, 214,116, 113, and 500/600 lobby area. Census: 98. Findings included: a) Resident rooms --room [ROOM NUMBER]: On 07/09/19 at 08:19 AM, chipped floor tiles were observed where the TV was located. The electrical plate did not cover the opening to the outlet creating a gapped area in the wall. --room [ROOM NUMBER]: On 07/09/19 at 08:28 AM, holes were observed above the window and the wooden board behind bed was chipped. --room [ROOM NUMBER]: On 07/08/19 at 11:51 AM, a scuff was observed on the bathroom door frame and scuffs were on the floor with indentation marks in the floor tile. --room [ROOM NUMBER]: On 07/08/19 at 01:09 PM, a Geri chair was observed to have a tattered right chair arm. --room [ROOM NUMBER]: On 07/09/19 at 08:28 AM, observations revealed the baseboard was scratched behind the bed. There were holes in the wall above the window. The seal around the toilet was stained. The ceiling vent was dirty. --room [ROOM NUMBER]: On 07/09/19 at 07:45 AM, a blanket was rolled under the air conditioner (A/C) Unit. An interview with Resident #57 on 07/09/19 at 08:53 AM, revealed the AC leaks. A large scraped area was noted to have been spackled but was not painted. --room [ROOM NUMBER]: On 07/08/19 at 10:53 AM, a hole was observed in the inside of the bathroom door. --room [ROOM NUMBER]: On 07/08/19 at 01:20 PM , there were large scrapes in the wall behind the bed board. --room [ROOM NUMBER]: On 07/09/19 on 08:18 AM, the floor tile was chipped in the area by the bed. --room [ROOM NUMBER]: On 07/08/19 at 10:58 AM, there was a hole in the floor tile by the window. A scuff on the wall was observed by the sink on the wall. An interview on 07/10/19 at 12:41 PM, with the Environmental Service Director, verified she was aware of the identified environment issues and tried to make rounds every week to identify areas that need fixed.",2020-09-01
909,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,600,J,0,1,9FZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to provide care and services in a manner that was free from sexual abuse. The findings were determined to pose an immediate jeopardy to the health and well-being of the residents. The facility Administrator was notified of the Immediate Jeopardy on 07/10/19 at 11:50 AM. The facility provided a Abatement Plan of Correction on 07/10/19 at 2:26 PM. The Abatement Plan of Correction was accepted by the state survey agency on 07/10/19 at 2:30 PM. The facility's Abatement Plan of Correction was: --Resident #89's care plan was reviewed and updated on (MONTH) 10, 2019 by facility social worker for sexually inappropriate behaviors. --Resident #89 was placed on 1:1 staff supervision on (MONTH) 10, 2019. --Resident #89's medical power of attorney was notified of 1:1 supervision and alleged incident on (MONTH) 10, 2019. --A psychiatry consultation will be scheduled for resident #89 by the Social Worker/designee by (MONTH) 10, 2019. Resident #89 was seen by the physician on (MONTH) 10, 2019 in relation to history of sexually inappropriate behaviors with recommendations to continue current medications and begin 1:1 supervision. --An initial audit of all nursing documentation since (MONTH) 6, 2019 for allegations of abuse will be completed by the Administrator/designee by (MONTH) 10, 2019. Any allegations will be immediately reported and investigated within 5 days. --All residents will be interviewed to determine if there are any allegations of abuse by the Administrator/designee by (MONTH) 10, 2019. Any allegations will be immediately reported and investigated within 5 days. --All facility staff will be educated on the definition of abuse and facility reporting procedures by the Staff Development Coordinator/designee by (MONTH) 12, 2019. Education began on (MONTH) 10, 2019. --Facility social worker will be educated on facility policy and procedure for investigation of abuse allegations by the Administrator/designee by (MONTH) 12, 2019. Education began on (MONTH) 10, 2019. The immediate jeopardy was abated on 07/10/19 at 3:30 PM. Upon abatement, the deficient practice scope and severity was reduced to a D. This practice affected one (1) of three (3) reportable incidents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #89 and #252. Facility census: #98. Findings included: a) Policy Review A review of the facility's policy Abuse Neglect and Exploitation with an implementation date of 11/27/17 was reviewed on 07/10/19. The policy stated Sexual abuse is non-consensual contact of any type with a resident. b) Record Review A review of the medical record for Resident #89, on 07/10/19 at 10:45 AM, revealed the Resident was admitted to the facility on [DATE] with the primary [DIAGNOSES REDACTED]. The Resident was alert and able to make his needs known upon admission. The resident was able to walk on his own. The Resident did not have capacity. The Resident had a healthcare surrogate. A review of the medical record for Resident #252, 07/10/19 at 10:55 AM, revealed the Resident was admitted to the facility on [DATE] with fractures sustained from a motorcycle accident. The Resident was fully capacitated. The Resident was discharged from the facility to home on 06/11/19. A review of the Nurses Notes for Resident #89, on 07/10/19 at 11:50 AM, revealed the following note: --06/06/19 at 10:45 AM-Resident #89 inappropriately touched a female resident's breast. The female was Resident #252. Further review of the medical records for Resident #89 and #252, on 07/10/19 at 11:05 AM, revealed no documentation the incident was investigated by anyone. Further review of the Nurses Notes for Resident #89, on 07/10/19 at 11:10 AM, revealed the following notes involving other instances of inappropriate sexual behavior with the Resident: -05/13/19 at 1:25 PM-Resident #89 is sexually inappropriate with staff and difficult to redirect. No documentation the physician or resident representative was notified. -05/14/19 at 7:25 AM-Resident #89 is combative with care, physically/verbally/sexually inappropriate with staff. No documentation the physician or resident representative was notified. -05/15/19 at 7:25 AM-Resident #89 has behaviors, sexual, physical and verbal. Resident is one on one for these behaviors as of right now. No documentation the physician or resident representative was notified. -05/16/19 at 7:25 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. No documentation the physician or resident representative was notified. -05/18/19 at 7:25 AM-Resident #89 has inappropriate sexual behavior with CNAs and other staff. No documentation the physician or resident representative was notified. -05/20/19 at 7:25 AM-Resident #89 makes sexual remarks. No documentation the physician or resident representative was notified. -05/22/19 at 3:14 AM-Resident #89 stated he did not want to hurt anyone, but is going to. -05/23/19 at 7:25 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. No documentation the physician or resident representative was notified. -05/29/19 at 11:10 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. No documentation the physician or resident representative was notified. c) Interviews An interview with the Director of Nursing (DON), on 07/10/19 at 11:15 AM, revealed Resident #252 had reported to the staff that Resident #89 touched her breast inappropriately on 06/06/19. The DON verified there was no documentation in Resident #252's record concerning the incident. The DON stated she did not know Resident #252 reporting that her breast was touched inappropriately was an allegation of sexual abuse. The DON stated there was no investigation completed and that there were no physician interventions put into place for the allegation on 06/06/19. The DON stated she could not provide any documentation showing that either Resident involved was assessed immediately after the incident occurred. An interview with the Clinical Continuous Quality Coordinator (CCQC), on 07/10/19 at 11:20 AM, revealed the incident on 06/06/19 with Resident #89 and Resident #252 was an allegation of sexual abuse. The CCQC verified there was no documentation in Resident #252's record concerning the incident on 06/06/19. The CCQC verified no investigation was completed concerning the alleged sexual abuse. An interview with the Administrator, on 07/10/19 at 11:30 AM, revealed she could not provide any documentation from 06/06/19 that assessments were done concerning the allegation, nor an investigation being initiated for Resident #89 or Resident #252 concerning the allegation of sexual abuse. The facility's failure to understand the definition of sexual abuse and the need to conduct an investigation posed an immediate jeopardy situation. A review of the Nurses Notes for Resident #89, on 07/10/19 at 11:50 AM, revealed the following note: -06/06/19 at 10:45 AM-Resident #89 inappropriately touched a female resident's breast. The female was Resident #252. Further review of the medical records for Resident #89 and #252, on 07/10/19 at 11:05 AM, revealed no documentation the physician was contacted for either resident concerning this incident. The Resident Representative for Resident #89 was also not notified. Resident #252's record had no documentation about the incident with her breast being touched by Resident #89. There is no documentation the incident was investigated or reported to anyone.",2020-09-01
910,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,609,D,0,1,9FZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure that an allegation of sexual abuse was reported immediately, but not later than 2 hours after the allegation is made, to the administrator of the facility and to other officials (including to the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. The facility did not report an incident involving a male resident inappropriately touching a female resident's breast. This practice affected one (1) of three (3) reportable incidents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #89 and #252. Facility census: #98. Findings included: a) Policy Review 1. Abuse Neglect and Exploitation Policy A review of the facility's policy Abuse Neglect and Exploitation with an implementation date of 11/27/17 was reviewed on 07/10/19. The policy stated Sexual abuse is non-consensual contact of any type with a resident. 2. Compliance with Reporting Allegations of Abuse Neglect and Exploitation Policy A review of the facility's policy Compliance with Reporting Allegations of Abuse Neglect Exploitation with an implementation date of 11/27/17 was reviewed on 07/10/19. The policy stated: --The Center is to report all allegations of abuse/neglect/exploitation to the appropriate agencies in accordance with current state and federal regulations. --Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. --The Center will report all alleged violations to the state agency and to all other agencies as required. --The Licensed Nurse or designee will respond to the needs of the resident and protect him/her from further incident, notify the Director of Nursing and Administrator, notify the attending physician, resident's family, and medical director, monitor and document the resident's condition-including response to medical intervention and nursing interventions, document actions taken in the medical record, and complete an incident report and initiate an investigation. --The Director of Nursing, Administrator, or designee will notify the appropriate agencies immediately, as soon as possible, no later than 24 hours after the discovery of the incident, obtain statements from the direct care staff, and follow up with the appropriate agencies to confirm the report was received. b) Record Review A review of the medical record for Resident #89, on 07/10/19 at 10:45 AM, revealed the Resident was admitted to the facility on [DATE] with the primary [DIAGNOSES REDACTED]. The Resident was alert and able to make his needs known upon admission. The resident was able to walk on his own. The Resident did not have capacity. The Resident had a healthcare surrogate. A review of the medical record for Resident #252, 07/10/19 at 10:55 AM, revealed the Resident was admitted to the facility on [DATE] with fractures sustained from a motorcycle accident. The Resident was fully capacitated. The Resident was discharged from the facility to home on 06/11/19. A review of the Nurses Notes for Resident #89, on 07/10/19 at 11:50 AM, revealed the following note: --06/06/19 at 10:45 AM-Resident #89 inappropriately touched a female resident's breast. The female was Resident #252. Further review of the medical records for Resident #89 and #252, on 07/10/19 at 11:05 AM, revealed no documentation the physician was contacted for either resident concerning this incident. The Resident Representative for Resident #89 was also not notified. Resident #252's record had no documentation about the incident with her breast being touched by Resident #89. There is no documentation the incident was reported to anyone. c) Interviews An interview with the Director of Nursing (DON), on 07/10/19 at 11:15 AM, revealed Resident #252 had reported to the staff that Resident #89 touched her breast inappropriately on 06/06/19. The DON stated she had no documentation that the physician or resident representative had been contacted concerning the incident. The DON verified there was no documentation in Resident #252's record concerning the incident. The DON stated she did not know Resident #252 reporting that her breast was touched inappropriately was an allegation of sexual abuse. The DON stated she could not provide any documentation showing protects were put in place to protect the resident. An interview with the Clinical Continuous Quality Coordinator (CCQC), on 07/10/19 at 11:20 AM, revealed the incident on 06/06/19 with Resident #89 and Resident #252 was an allegation of sexual abuse. The CCQC verified no incident report was completed nor was the incident reported to the state. The CCQC stated the incident was reported on 07/10/19 (after surveyor intervention) to all the required agencies. An interview with the Administrator, on 07/10/19 at 11:30 AM, revealed she could not provide any documentation from 06/06/19 the allegation of sexual abuse was reported to the required state agencies within 2 hours of notification of the allegation.",2020-09-01
911,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,610,D,0,1,9FZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to have evidence that an alleged violation of sexual abuse was thoroughly investigated. The facility did not investigate an incident involving a male resident inappropriately touching a female resident's breast. In addition, they failed to implement protections for the resident (alleged victim) while the investigation was conducted. This failed practice affected one (1) of three (3) reportable incidents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #89 and #252. Facility census: #98. Findings included: a) Policy Review A review of the facility's policy Abuse Neglect and Exploitation with an implementation date of 11/27/17 was reviewed on 07/10/19. The policy stated Sexual abuse is non-consensual contact of any type with a resident. b) Record Review A review of the medical record for Resident #89, on 07/10/19 at 10:45 AM, revealed the Resident was admitted to the facility on [DATE] with the primary [DIAGNOSES REDACTED]. The Resident was alert and able to make his needs known upon admission. The resident was able to walk on his own. The Resident did not have capacity. The Resident had a healthcare surrogate. A review of the medical record for Resident #252, 07/10/19 at 10:55 AM, revealed the Resident was admitted to the facility on [DATE] with fractures sustained from a motorcycle accident. The Resident was fully capacitated. The Resident was discharged from the facility to home on 06/11/19. A review of the Nurses Notes for Resident #89, on 07/10/19 at 11:50 AM, revealed the following note: --06/06/19 at 10:45 AM-Resident #89 inappropriately touched a female resident's breast. The female was Resident #252. Further review of the medical records for Resident #89 and #252, on 07/10/19 at 11:05 AM, revealed no documentation the incident was investigated by anyone. c) Interviews An interview with the Director of Nursing (DON), on 07/10/19 at 11:15 AM, revealed Resident #252 had reported to the staff that Resident #89 touched her breast inappropriately on 06/06/19. The DON verified there was no documentation in Resident #252's record concerning the incident. The DON stated she did not know Resident #252 reporting that her breast was touched inappropriately was an allegation of sexual abuse. The DON stated there was no investigation completed and that there were no physician interventions put into place for the allegation on 06/06/19. The DON stated she could not provide any documentation showing that either Resident involved was assessed immediately after the incident occurred. An interview with the Clinical Continuous Quality Coordinator (CCQC), on 07/10/19 at 11:20 AM, revealed the incident on 06/06/19 with Resident #89 and Resident #252 was an allegation of sexual abuse. The CCQC verified there was no documentation in Resident #252's record concerning the incident on 06/06/19. The CCQC verified no investigation was completed concerning the alleged sexual abuse. An interview with the Administrator, on 07/10/19 at 11:30 AM, revealed she could not provide any documentation from 06/06/19 that assessments were done concerning the allegation, nor an investigation being initiated for Resident #89 or Resident #252 concerning the allegation of sexual abuse.",2020-09-01
912,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,656,D,0,1,9FZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs. A care plan was not developed for a resident with multiple sexual behaviors towards staff and another resident. This practice affected one (1) of twenty-three (23) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifier: #89. Facility census: 98. Findings included: a) Record Review A review of the medical record for Resident #89, on 07/10/19 at 10:45 AM, revealed the Resident was admitted to the facility on (MONTH) 2019 with the primary [DIAGNOSES REDACTED]. The Resident did not have capacity. The Resident had a healthcare surrogate. A review of the Nurses Notes for Resident #89, on 07/10/19 at 11:50 AM, revealed the following note: --06/06/19 at 10:45 AM-Resident #89 inappropriately touched a female resident's breast. Further review of the Nurses Notes for Resident #89, on 07/10/19 at 11:10 AM, revealed the following notes involving other instances of inappropriate sexual behavior with the Resident: --05/13/19 at 1:25 PM-Resident #89 is sexually inappropriate with staff and difficult to redirect. --05/14/19 at 7:25 AM-Resident #89 is combative with care, physically/verbally/sexually inappropriate with staff. --05/15/19 at 7:25 AM-Resident #89 has behaviors, sexual, physical and verbal. Resident is one on one for these behaviors as of right now. --05/16/19 at 7:25 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. --05/18/19 at 7:25 AM-Resident #89 has inappropriate sexual behavior with CNAs and other staff. --05/20/19 at 7:25 AM-Resident #89 makes sexual remarks. --05/23/19 at 7:25 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. --05/29/19 at 11:10 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. --06/09/19 at 8:26 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. Further review of the medical record for Resident #89, on 07/10/19 at 11:05 AM, revealed no documentation the the care plan was updated to reflect the inappropriate sexual behaviors exhibited from 05/13/19 through 06/09/19. b) Interview An interview with the Director of Nursing (DON), on 07/10/19 at 11:15 AM, revealed the Care Plan for Resident #89 was not updated to reflect the Resident's sexual behaviors until 07/10/19 after this surveyor identified the issue.",2020-09-01
913,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,657,E,0,1,9FZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to revise care plans in accordance with the professional standards of practice. The facility failed to revise care plans for five (5) residents related to pressure ulcers, tube feeding, advance directives, and catheters. This failed practice affected five (5) of 23 residents. Resident identifiers: #91, #93, #68, #34 and #59. Facility census: 98. Findings included: a) Resident #34 A record review of a physician order [REDACTED]. The front of Resident #34's physical chart stated DNR. Additional record review of the care plan, on [DATE], revealed Full Code: Resident's resuscitation status is RESUSCITATE Date Initiated: [DATE] Revision on: [DATE]. Resident's wishes will be honored through next review. Date Initiated: [DATE] Revision on: [DATE] Target Date: [DATE]. If resident is found to be without pulse or breathing, immediately call 911 and begin CPR Date Initiated: [DATE]. Notify MD and family immediately of change in condition. Date Initiated: [DATE]. Once CPR has been initiated, continue until EMS arrives and takes over Date Initiated: [DATE] An interview with DoN, on [DATE] at 1:00 PM, confirmed that the care plans for both Resident #34 and Resident #68 were wrong and the care plans were not revised to reflect the physician orders [REDACTED]. b) Resident #59 An observation, on [DATE] at 9:00 AM, revealed Resident #59's catheter bag was laying on the floor beside bed. An interview with DoN, on [DATE] at 9:05 AM, revealed Resident #59's catheter bag falls on the floor all the time. A record review of the care plan, on [DATE], revealed no focus, goal or intervention related to Resident #59's catheter bag being found frequently on the floor. c) Resident #91 Review of the care plan for Resident #91, on [DATE] at 09:59 AM, showed the resident's problem as having a pressure ulcer on the left buttock with interventions to provide a treatment to that area. Further review of the medical record revealed the pressure ulcer had healed as of [DATE], but no revision had been made to the current care plan. An interview on [DATE] at 01:30 PM, with the DON , revealed the care plan had not been revised even though the pressure ulcer was assessed as healed on ,[DATE]. It was further stated by the DON, the care plan should have been revised within 72 hours of noting the pressure ulcer being healed. d) Resident #93 On [DATE] at 11:00 AM Resident #93's tube feed was observed to be, [MEDICATION NAME] 1.0 cal, a fiber-fortified therapeutic nutrition. Also observed a kangaroo bag used for flushing the tubing with no open date or initials for who opened it. The physician order, with a start date of [DATE], is [MEDICATION NAME] 1.2 cal every eighteen (18) hours @75 millimeters (ml) per hour on at four (4) PM and off at ten (10) AM. On [DATE] at 8:00 AM observation found tube feed to be [MEDICATION NAME] 1.0 cal. At 10:10 AM on [DATE] licensed nurse (LPN) #51 explained that a few months ago the order was changed from [MEDICATION NAME] 1.0 to [MEDICATION NAME] 1.2 due to the 1.0 not being available. Upon availability the order should have been changed back to 1.0, but was not. At 10:19 AM LPN #57 confirmed the [MEDICATION NAME] running is 1.0 cal and the kangaroo bag is not labeled with a date and initials. The cooperate consultant agreed the physician order [REDACTED]. Review of Resident #93's care plan with a revision date of [DATE] found a problem of, risk for aspiration related to tube feed with an intervention of [MEDICATION NAME] 1.0 cal. An additional problem on the care plan of significant weight gain in six months, related to tube feeding, with a revision date of [DATE] found an intervention of [MEDICATION NAME] 1.2 cal The facility failed to identify the two different [MEDICATION NAME] interventions on the care plan and make revisions in accordance to the physician order. e) Resident #68 On [DATE] review of Resident #68's care plan revealed a Full Code status. Review of code status found a post form with a date of [DATE] documented as, Do Not Attempt Resuscitation/DNR. The electronic records reveals a physician order [REDACTED]. On [DATE] the director of nursing (DON) agreed the care plan had not been revised to show the status of Resident #68.",2020-09-01
914,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,677,D,0,1,9FZF11,"Based on observation, record review and staff interview, the facility failed to provide a resident who could not carry out activities of daily living (ADLS) , the necessary services to maintain good grooming for one (1) of 23 sampled residents . Resident identifier: #37 Findings included: Observations on 07/08/19 at 12:18 PM, revealed Resident #37 had long dirty fingernails. An observation on 07/09/19 at 12:10 PM, revealed Resident #37 continued to have the long dirty fingernails. Review of the care plan, on 07/09/19 at 12:15 PM, showed that Resident #37 to be at risk for decline in Activities of Daily living (ADLs), with an intervention requiring assistance of one staff for hygiene. An interview with the DON on 07/09/19 at 03:00 PM, verified Resident #37's fingernails were dirty and there was no documentation of care being completed or care not attempted because of refusal noted.",2020-09-01
915,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,684,D,0,1,9FZF11,"**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 ensurephysician orders [REDACTED]. This practice affected 1 of 23 residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #150. Facility census: 98. Findings included: a) Resident #150 An interview with R#150, on 07/08/19 at 11:53 AM, revealed the dressing on the right arm covering a peripherally Inserted Central Catheter (PICC) had not been changed since coming to the facility. The resident stated this is the same dressing as I had in the hospital. A record review on 07/09/19 at 01:00 PM, noted a physician's orders [REDACTED]. to change the PICC line dressing every week- one time a day on Friday. A review of the treatment record showed no evidence the treatment was provided 07/05/19 (Friday) as ordered by the physician. An interview on 07/09/19, at 1:30 PM, with the DON, confirmed the dressing ordered 07/05/19 had not been done.",2020-09-01
916,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,689,D,0,1,9FZF11,"Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which it had control. A shower room that contained razors and chemical substances was open for anyone to access. This practice had the potential to affect a limited number of residents. Room identifier: 600 Hallway Shower Room. Facility census: 98. Findings included: a) 600 Hallway Shower Room An observation of the 600 Hallway Shower Room, on 07/08/19 at 10:45 AM, revealed the room was not locked and accessible to anyone. The room contained the following items: --Three (3) containers of Medspa Shave Cream with the warning Keep out of reach of children. --Two (2) containers of Remedy Phytoplex Cleanser with the warning For external use only. --Two (2) 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. --Seven (7) capped shaving razors. An interview with Licensed Practical Nurse (LPN) #125, on 07/08/19 at 10:50 AM, revealed the Shower Room is usually unlocked. The LPN stated the razors and grooming products should be locked up.",2020-09-01
917,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,693,D,0,1,9FZF11,"**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 received tube feeding in accordance with the physician order [REDACTED]. This is true for one (1) of one (1) residents reviewed for tube feeding. Resident identifier: #93. Facility census: 93. Findings included: a) Resident #93 On 07/08/19 at 11:00 AM Resident #93's tube feed (not running) was observed to be [MEDICATION NAME] 1.0 cal, a fiber-fortified therapeutic nutrition. Also observed a kangaroo bag used for flushing the tubing with no open date or initials for who opened it. The physician order, with a start date of 05/13/19, is [MEDICATION NAME] 1.2 cal every eighteen (18) hours @75 millimeters (ml) per hour on at four (4) PM and off at ten (10) AM. On 07/09/19 at 8:00 AM observation found tube feed to be [MEDICATION NAME] 1.0 cal. At 10:10 AM on 07/09/19 licensed nurse (LPN) #51 explained that a few weeks ago the order was changed from [MEDICATION NAME] 1.0 to [MEDICATION NAME] 1.2 due to the 1.0 not being available. Upon availability the order should have been changed back to 1.0. At 10:19 AM LPN #57 confirmed the [MEDICATION NAME] running is 1.0 cal and the kangaroo bag is not labeled with a date and initials. The cooperate consultant agreed the physician order [REDACTED].",2020-09-01
918,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,695,D,0,1,9FZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to provide respiratory care consistent with the professional standards of practice. The facility failed to administer oxygen to a resident at the correct flow rate as indicated on the physician order. The failed practice affected one (1) of eight (8) residents. Resident identifier: #22. Facility census: 98. Findings included: a) Resident #22 On observation, on 07/08/19 at 1:09 PM, revealed Resident #22 was being administered oxygen via nasal cannula at three (3) liters per minute. A record review of a physician order [REDACTED]. Notify the physician. A second observation, on 07/09/19 at 12:00 PM, revealed Resident #22 was being administered oxygen via nasal cannula at three (3) liters per minute. An interview with Registered Nurse (RN) #44, on 07/09/19 at 12:03 PM, revealed the oxygen flow rate for Resident #22 is ordered for two (2) liters per minute. RN #44 confirmed Resident #22 being administered oxygen at three (3) liters per minute via nasal cannula was not the correct flow rate.",2020-09-01
919,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,730,D,0,1,9FZF11,"Based on personnel record review and staff interview, the facility failed to ensure a performance review was conducted on each nurse aide at least once every 12 months. This practice affected two (2) of five (5) nurse aides reviewed during the Long Term Care Survey Process (LTCSP). Staff identifiers: #1 and #2. Facility census: 98. Findings include: a) Nurse Aide #1 A review of Nurse Aide (NA) #1's Annual Performance Review (APR), on 07/10/19 at 8:55 AM, revealed the NA was hired on 07/21/04. The NA's last APR was conducted on 07/21/16. b) Nurse Aide #2 A review of NA #2's APR, on 07/10/19 at 9:05 AM, revealed the NA was hired on 02/21/91. The NA's last two APRs were conducted on 06/27/17 and 02/21/19. There was no APR conducted in (YEAR). c) Interview An interview with the Human Resource Manager (HRM), on 07/10/19 at 9:25 AM, revealed the APRs for the nurse aides are supposed to be conducted yearly on the anniversary of their hire date or from the date of their last performance evaluation. The HRM verified NA #1 did not have an APR completed since (YEAR) and NA #2 did not have an APR completed on 06/27/18 or 02/21/18 as required. The HRM stated she was new and was trying to get all the APRs updated.",2020-09-01
920,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,758,D,0,1,9FZF11,"**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's drug regimen was free from an unnecessary [MEDICAL CONDITION] drug. An anti-psychotic medication did not have an acceptable [DIAGNOSES REDACTED]. This practice affected one (1) of six (6) residents reviewed for unnecessary medications during the Long Term Care Survey Process (LTCSP). Resident identifier: #251. Facility census: 98. Findings included: a) Resident #251 A record review, on 07/09/19 at 11:30 AM, revealed the Resident had a physician order [REDACTED]. There was no documentation in the record concerning the medication being ordered for a [DIAGNOSES REDACTED]. An interview with the Clinical Continuous Quality Coordinator (CCQC), on 07/09/19 at 1:35 PM, revealed nausea, vomiting, and restlessness is not an acceptable [DIAGNOSES REDACTED]. The CCQC stated those are symptoms and not an acceptable diagnosis. The CCQC verified there was no documentation besides the order for the Anti-psychotic medication.",2020-09-01
921,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,761,D,0,1,9FZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff 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. Multiple opened medications stored in the 100 Hall Medication Cart were unlabeled and undated. This practice had the potential to affect a limited number of residents. Facility census: 98. Findings included: a) 100 Hall Medication Cart An observation of the 100 Hall Medication Cart, on 07/10/19 at 7:35 AM, revealed the following medications were opened, undated, and unlabeled: --One (1) bottle of [MEDICATION NAME] Cough Syrup --One (1) bottle of [MEDICATION NAME] --One (1) bottle of [MEDICATION NAME] stock medication An interview with Licensed Practical Nurse (LPN) #46, on 07/10/19 at 7:38 AM, revealed all medications should be labeled and dated when opened. The LPN stated this is my cart so I am not sure how I missed those medications. The LPN stated she would discard the medications.",2020-09-01
922,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,812,D,0,1,9FZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to discard expired food and label a container placed in the refrigerator. The failed practice had the potential to affect a limited number of residents. Facility census: 98. Finding included: a) Kitchen During the initial tour of the kitchen, on [DATE] at 10:15 AM, there was a five (5) pound bag of finely shredded lettuce that was expired with a date of [DATE]. There was a 16 ounce container of Minor's Beef Base Low Sodium with no labeled date of when the facility received or stored the food item. The manufactures date on the can stated [DATE] with no year indicated. An interview with Dietary Manager (DM), on [DATE] at 10:18 AM, confirmed the bag of lettuce was expired and should have been discarded. DM also confirmed the Minors Beef Base container was not labeled with a date. DM proceeded to discard the items immediately from the refrigerator.",2020-09-01
923,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,835,E,0,1,9FZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to administer operations in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility did not report, investigate, contact the physician or resident representative, or assess, residents involved in an allegation of sexual abuse. The failure to administer operations had the potential to affect all residents in the facility. Resident identifiers: #89 and #252. Facility census: #98. Findings included: a) Policy Review 1. Notification of Changes Facility Policy A review of the facility's policy Notification of Changes with an implementation date of 11/27/17 was reviewed on 07/10/19. The policy stated the facility is to ensure the Center promptly informs the resident, consult's the resident's physician; and notify, consistent with his or her authority, resident representative when there is a change requiring notification. This includes competent individuals. Circumstances requiring notification include a resident's physical, mental, or psychosocial condition. 2. Compliance with Reporting Allegations of Abuse Neglect Exploitation Facility Policy A review of the facility's policy Compliance with Reporting Allegations of Abuse Neglect Exploitation with an implementation date of 11/27/17 was reviewed on 07/10/19. The policy stated The Center is to report all allegations of abuse/neglect/exploitation to the approprpriate agencies in accordance with current state and federal regulations. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. The Licensed Nurse or designee will respond to the needs of the resident and protect him/her from further incident, notify the Director of Nursing and Administrator, notify the attending physician, resident's family, and medical director, monitor and document the resident's condition-including response to medical intervention and nursing interventions, document actions taken in the medical record, and complete an incident report and initiate an investigation. b) Record Review A review of the medical record for Resident #89, on 07/10/19 at 10:45 AM, revealed the Resident was admitted to the facility on [DATE] with the primary [DIAGNOSES REDACTED]. The Resident was alert and able to make his needs known upon admission. The resident was able to walk on his own. The Resident did not have capacity. The Resident had a healthcare surrogate. A review of the medical record for Resident #252, 07/10/19 at 10:55 AM, revealed the Resident was admitted to the facility on [DATE] with fractures sustained from a motorcycle accident. The Resident was fully capacitated. The Resident was discharged from the facility to home on 06/11/19. A review of the Nurses Notes for Resident #89, on 07/10/19 at 11:50 AM, revealed the following note: -06/06/19 at 10:45 AM-Resident #89 inappropriately touched a female resident's breast. The female was Resident #252. Further review of the medical records for Resident #89 and #252, on 07/10/19 at 11:05 AM, revealed no documentation the physician was contacted for either resident concerning this incident. The Resident Representative for Resident #89 was also not notified. Resident #252's record had no documentation about the incident with her breast being touched by Resident #89. There is no documentation the incident was investigated, reported to anyone, or that the residents were assessed. Further review of the Nurses Notes for Resident #89, on 07/10/19 at 11:10 AM, revealed the following notes involving other instances of inappropriate sexual behavior with the Resident: -05/13/19 at 1:25 PM-Resident #89 is sexually inappropriate with staff and difficult to redirect. No documentation the physician or resident representative was notified. -05/14/19 at 7:25 AM-Resident #89 is combative with care, physically/verbally/sexually inappropriate with staff. No documentation the physician or resident representative was notified. -05/15/19 at 7:25 AM-Resident #89 has behaviors, sexual, physical and verbal. Resident is one on one for these behaviors as of right now. No documentation the physician or resident representative was notified. -05/16/19 at 7:25 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. No documentation the physician or resident representative was notified. -05/18/19 at 7:25 AM-Resident #89 has inappropriate sexual behavior with CNAs and other staff. No documentation the physician or resident representative was notified. -05/20/19 at 7:25 AM-Resident #89 makes sexual remarks. No documentation the physician or resident representative was notified. -05/22/19 at 3:14 AM-Resident #89 stated he did not want to hurt anyone, but is going to. -05/23/19 at 7:25 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. No documentation the physician or resident representative was notified. -05/29/19 at 11:10 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. No documentation the physician or resident representative was notified. -06/09/19 at 8:26 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. No documentation the physician or resident representative was notified. c) Interviews An interview with the Director of Nursing (DON), on 07/10/19 at 11:15 AM, revealed Resident #252 had reported to the staff that Resident #89 touched her breast inappropriately on 06/06/19. The DON stated she had no documentation that the physician or resident representative had been contacted concerning the incident. The DON verified there was no documentation in Resident #252's record concerning the incident. The DON stated she did not know Resident #252 reporting that her breast was touched inappropriately was an allegation of sexual abuse. The DON stated she had no idea the physician or resident representative had to be contacted for the incident. The DON stated there was no investigation completed and that there were no physician interventions put into place for the allegation on 06/06/19. The DON stated she could not provide any documentation showing that either Resident involved was assessed immediately after the incident occurred. An interview with the Clinical Continuous Quality Coordinator (CCQC), on 07/10/19 at 11:20 AM, revealed the incident on 06/06/19 with Resident #89 and Resident #252 was an allegation of sexual abuse. The CCQC stated the physician and all responsible parties should have been notified immediately upon the report of the allegation. The CCQC stated she had reviewed the records for Resident #89 and Resident #252 and there was no documentation the physician or responsible parties were notified. The CCQC verified there was no documentation in Resident #252's record concerning the incident on 06/06/19. The CCQC verified no incident report was completed nor was the incident reported to the state. The CCQC stated the incident was reported on 07/10/19 to all the required agencies. The CCQC also stated all required parties would be notified on 07/10/19 as well. An interview with the Administrator, on 07/10/19 at 11:30 AM, revealed she could not provide any documentation from 06/06/19 that assessments were done concerning the allegation, a reportable being conducted, an investigation being initiated, nor notification of the physician or resident representative, was done for Resident #89 or Resident #252. An interview with the facility's Medical Director and Physician to Resident #89 and #252, on 07/10/19 at 12:30 PM, revealed he does not remember being contacted about the incident where Resident #89 touched Resident #252's breast. The Medical Director agreed he should have been notified.",2020-09-01
924,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,849,D,0,1,9FZF11,"**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 ensure residents had physician orders [REDACTED]. Resident identifiers: #251 and #34. Facility census: 98. Findings included: a) Resident #251 A review of the medical record, on 07/09/19 at 1:55 PM, revealed the Resident was admitted to the facility on hospice services on 07/01/19. There was no order for hospice in the record until 07/08/19. An interview with the Clinical Continuous Quality Coordinator (CCQC), on 07/09/19 at 2:30 PM, revealed the hospice order was not written and in the medical record until 07/08/19. b) Resident #34 A record review of progress notes, on 07/08/19 at 1:00 PM, revealed Resident #34 was visited by Valley Hospice on 07/05/19. Further record review of physician orders, on 07/08/19, revealed no current physician order [REDACTED].>A staff interview with DoN, on 07/08/19 at 1:20 PM, revealed Hospice was just started for Resident #34 on 07/05/19. DoN stated, Valley Hospice has not even sent their treatment plan yet. A record review of physician orders, on 07/09/19, revealed a physician order [REDACTED]. Order stated, Admit to Valley Hospice. DX: Unspecified [MEDICAL CONDITION] of the liver. (Order date 06/05/19) Created Date: 7/8/2019 15:27. An interview with Clinical Quality Coordinator (CQC), on 07/09/19 at 3:05 PM, revealed Hospice was started on 07/05/19. The physician order [REDACTED]. CQC stated the date will be changed to reflect the correct order date of 07/05/19.",2020-09-01
925,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,880,D,0,1,9FZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy review, the facility failed to ensure that linens were handled in accordance with infection control guidelines and practices, failed to ensure staff used appropriate personal protective equipment when handling soiled linen and failed to provide an infection control program to ensure urinary catheters were cared for in a manner to prevent the spread of infection. This practice had the potential to affect a limited number of residents residing in the facility. Resident identifier: #59. Facility census: 98. Findings included: a) Observation During a observation on 07/09/19, at 10:20 AM, soiled, wet linens were observed outside room [ROOM NUMBER] laying directly on the floor in the hallway. HK#118 was observed to drag the linen back inside the doorway of room [ROOM NUMBER] by holding it with an ungloved right hand. An interview on 07/09/19, at 10:20 AM, HK#118 revealed the resident in the room had placed a soiled diaper in the toilet and had stopped it up causing the toilet to overflow and the linen was used to wipe up the contents that overflowed from the toilet. HK# 118, further added, the linen was not bagged because it would have been too heavy. On 07/09/19, at 12:14 PM, an interview with the Director of Nursing (DON), confirmed putting soiled linen on the floor is a problem. A review of the policy and procedure, titled Soiled Linen and Trash Containers, dated 10/2018, noted loose trash and linen shall be appropriately bagged before placing into a larger storage bin and staff shall wear appropriate personal protective equipment when handling soiled linen or trash. b) Resident #59 An observation, on 07/09/19 at 9:00 AM, revealed Resident #59's catheter bag was laying on the floor beside bed. An interview with DoN, on 07/09/19 at 9:05 AM, revealed Resident #59's catheter bag falls on the floor all the time. A record review of the care plan, on 07/09/19, revealed no focus, goal or intervention related to Resident #59's catheter bag being found frequently on the floor.",2020-09-01
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
946,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2017-03-22,156,D,0,1,SWUR11,"Based on resident interview, staff interview and facility record review, the facility failed to ensure residents received and/or were knowledgeable of how to contact State agencies for two (2) of four (4) residents interviewed. Residents were unable to articulate the name of the ombudsman, did not know the purpose of an ombudsman, and did not know how to contact State agencies, or where to find the information in the facility. Resident identifiers: Resident #13 and #126. Facility census: 117 Findings include: a) Resident #13 and #126 During an interview with Resident #126, on 03/22/17 at 10:31 a.m., the resident voiced concerns were reported to the facility staff. Upon inquiry, she said she did not know how to report to State agencies, and did not know the name of the ombudsman or how to contact her. Resident #13, interviewed at 10:38 a.m. on 03/22/17 at 10:38 a.m., said she would refer concerns to the facility. Upon inquiry, the resident said she did not know how to report to State agencies, and did not know how to contact the ombudsman, or the purpose of an ombudsman. Both residents, during the interviews, denied knowledge of where to find contact information for State agencies in the facility. An interview with Social Service Coordinator (SSC) #60, on 03/22/17 at 12:28 p.m., the SSC said signs were posted and residents and/or families were notified of reporting requirements during the 72 hour meeting on admission. When asked how the information was disseminated to all residents and/or families the coordinator said a copy of resident rights was given to residents yearly. Upon inquiry, the coordinator looked at the form and said it did not contain State agency contact information. The SSC confirmed residents were only provided contact information during resident council meetings.",2020-09-01
947,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2017-03-22,157,D,0,1,SWUR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the physician when ordered lab work was not completed for two (2) of five (5) Stage 2 sampled residents reviewed for unnecessary medications. Resident #78 was ordered a [MEDICATION NAME] Acid serum level which was not done. There was no evidence the physician was notified of the failure to follow this order. Resident #70 was ordered weekly complete blood count (CBC) blood tests. When a weekly test was omitted, there was no evidence the physician was notified of the failure to follow this order. Resident identifiers: #78 and #70. Facility census: 117. Findings include: a) Resident #78 The medical record was reviewed on 03/20/17. This resident received [MEDICATION NAME] delayed release (DR) 250 milligram (mg) twice daily to treat a diagnosed condition of dementia with behaviors. Physician orders on 01/28/17 directed to draw a [MEDICATION NAME] Acid level the next lab day, then every six (6) months thereafter. A [MEDICATION NAME] Acid level is used to assess the blood level of the medication [MEDICATION NAME]. Review of the lab reconciliation sheet found the phlebotomist was unable to draw blood for the [MEDICATION NAME] Acid level on 01/30/17 because the resident was combative. The reconciliation sheet contained a note the resident was rescheduled for the following day on 01/31/17. Night shift licensed practical nurse (LPN) #17 initialed the reconciliation sheet results of the negative outcome. Review of the 01/31/17 lab reconciliation sheet found this resident was the only resident scheduled on this date for lab work. The phlebotomist again attempted to draw blood for a [MEDICATION NAME] Acid level, but did not succeed because the resident was again combative. Night shift LPN #34 initialed to attest results were not obtained. Further review of the lab reconciliation sheets found this resident had blood drawn on 02/13/17 for a complete blood count and an iron level. There was no [MEDICATION NAME] Acid level drawn on this date. The medical record was further reviewed, and found no [MEDICATION NAME] Acid serum lab results within the medical record. The medical record was silent for physician notification of the failure to obtain a [MEDICATION NAME] Acid level for this resident. During an interview with registered nurse (RN) unit manager #61, on 03/20/17 at 2:15 p.m., she said she was unable to find any [MEDICATION NAME] Acid lab results for this resident. She was also unable to find any evidence the physician was notified of the failure to obtain a [MEDICATION NAME] Acid level. During an interview with the Director of Nursing, on 03/22/17 at 12:30 p.m., she had no further information to provide about the absence of the [MEDICATION NAME] Acid lab tests for this resident. She said she believed the nurse practitioner was informed when the resident was combative, but acknowledged she had no evidence to support that opinion. b) Resident #70 A review of the physician order for [REDACTED]. A review of Resident #70's medical record, on 03/21/17 at 11:30 p.m., revealed there was no results for the 12/08/16 (CBC) labs work in her medical record. The next day, on 03/22/17 at 11:30 a.m., the nurse practice educator registered nurse (NPE-RN) reviewed Resident #70's record and found the resident was combative, and the CBC was not obtained on this date. The NPE-RN was asked whether the physician was informed or obtained at another time. She said she had to look and see. A review of the Medication Administration Record [REDACTED]. The NPE-RN returned, on 03/22/17 at 12:10 p.m., and said she could not find the results for the CBC for 12/08/16. She said the phlebotomist from a hospital comes and obtains the lab work for the facility. She said she felt the staff told the nurse practitioner the lab work was not obtained. The NPE-RN verbalized that is no evidence the physician was notified, and no physician order to indicate the lab was ordered for another time or not to obtain the lab work for this week. The NP-RN confirmed the staff did not follow the physician order, nor notify the physician/nurse practitioner. On 03/22/17 12:35 p.m., the NP-RN said she reviewed the physician progress notes [REDACTED].",2020-09-01
948,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2017-03-22,225,D,0,1,SWUR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of reportable allegations, family interview, policy review and staff interview, the facility failed to investigate and/or report allegations of abuse and/or neglect in a timely manner for three (3) of five (5) allegations reviewed. Resident identifiers: #106, #98 and #143. Facility census: 117. Findings include: a) Resident #106 Reportable allegations reviewed, on 03/20/17 at 11:40 a.m., revealed an allegation dated 02/07/17 with an incident date of 02/04/17. The form indicated the family member had reported a concern to the Licensed Practical Nurse (LPN) on the evening of 02/04/17 related to a soiled bed and soiled clothing, and asked for the Nurse Aide (NA) to be removed from Resident #106's care. The family member called and spoke with the center nurse executive (CNE) on 02/06/17 regarding the incident. The CNE then initiated an allegation of abuse and/or neglect and began an investigation. The Social Services Coordinator (SSC) #60, interviewed on 03/22/17 at 9:30 a.m., reviewed the allegation and confirmed it was not reported timely to the administrator or the appropriate State agencies. An interview with the CNE, on 03/22/17, she said the LPN was not aware the family member had alleged neglect, which is why she did not report it. During an interview with Family Member #1, the FM related the event as an allegation of neglect. b) Resident #98 The reported allegation, dated 01/09/17, noted an incident date of 01/07/17. Resident #98 alleged she tried several times in the early morning to get someone to take her to the restroom and was unable, thus resulting in resident becoming incontinent on herself. She also stated she was left on the bedpan that same night for an extended amount of time. A concern/grievance form had been completed on 01/07/17 related to the incident. During the interview with Social Services Coordinator (SSC) #60, she confirmed the incident was not reported to facility staff and/or the appropriate State agencies within the correct timeframe. SSC #60 verbalized the concern form had been slid under her door and she found it upon return to work on 01/09/17, at which time she initiated an investigation and reported it to State agencies. c) Resident #143 An immediate fax reporting of allegations form, dated 02/06/17, indicated a nurse aide observed a linear, dark red abrasion on Resident #143 during a shower on 02/03/17. The resident was unable to give any information, but had a history of [REDACTED]. SSC #60, confirmed the allegation was not reported to State agencies within the appropriate time guidelines. During an interview with the CNE, on 03/22/17, she voiced the interdisciplinary team had reviewed the incident report during morning meeting, and was unable to determine how the resident may have self-inflicted the wound and initiated the investigation. The CNE verbalized the Licensed Practical Nurse (LPN) had assumed the wound may have been self-inflicted and did not recognize the need to immediately report it to the facility or to the appropriate State agencies. d) Review of facility abuse policy The abuse policy, reviewed on 03/20/17, noted a revision date of 07/16/13. The policy noted an injury of unknown origin as an injury which was not observed by any person or the source could not be explained by the patient; and the injury was suspicious because of the extent of the injury or the location of the injury. The policy indicated anyone who witnessed an incident of suspected abuse or neglect was to report the incident immediately to his/her supervisor and injuries of unknown origin would be investigated immediately to determine if abuse or neglect was suspected.",2020-09-01
949,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2017-03-22,226,E,0,1,SWUR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, staff interview and policy review, the facility failed to implement policies related to abuse and/or neglect for three (3) of five (5) residents with reportable allegations. The facility failed to ensure two (2) of four (4) residents and/or family members knew how to report an allegation to the appropriate State agencies. Resident identifiers: #106, #98, #143, #13 and #126. Facility census: 117. Findings include: a) Failure to implement policies related to abuse and/or neglect 1. Resident #106 Reportable allegations reviewed, on 03/20/17 at 11:40 a.m., revealed an allegation dated 02/07/17 with an incident date of 02/04/17. The form indicated the family member had reported a concern to the Licensed Practical Nurse (LPN) on the evening of 02/04/17 related to a soiled bed and soiled clothing, and asked for the Nurse Aide (NA) to be removed from Resident #106's care. The family member called and spoke with the center nurse executive (CNE) on 02/06/17 regarding the incident. The CNE then initiated an allegation of abuse and/or neglect and began an investigation. The Social Services Coordinator (SSC) #60, interviewed on 03/22/17 at 9:30 a.m., reviewed the allegation and confirmed it was not reported timely to the administrator or the appropriate State agencies. An interview with the CNE, on 03/22/17, she said the LPN was not aware the family member had alleged neglect, which is why she did not report it. During an interview with Family Member #1, the FM related the event as an allegation of neglect and verbalized a request had been made to have the nurse aide removed from Resident #106's care. 2. Resident #98 The reported allegation, dated 01/09/17, noted an incident date of 01/07/17. Resident #98 alleged she tried several times in the early morning to get someone to take her to the restroom and was unable, thus resulting in resident becoming incontinent on herself. She also stated she was left on the bedpan that same night for an extended amount of time. A concern/grievance form had been completed on 01/07/17 related to the incident. During the interview with Social Services Coordinator (SSC) #60, she confirmed the incident was not reported to facility staff and/or the appropriate State agencies within the correct timeframe. SSC #60 verbalized the concern form had been slid under her door and she found it upon return to work on 01/09/17, at which time she initiated an investigation and reported it to State agencies. 3. Resident #143 An immediate fax reporting of allegations form, dated 02/06/17, indicated a nurse aide observed a linear, dark red abrasion on Resident #143 during a shower on 02/03/17. The resident was unable to give any information, but had a history of [REDACTED]. SSC #60, confirmed the allegation was not reported to State agencies within the appropriate time guidelines. During an interview with the CNE, on 03/22/17, she voiced the interdisciplinary team had reviewed the incident report during morning meeting, and was unable to determine how the resident may have self-inflicted the wound and initiated the investigation. The CNE verbalized the Licensed Practical Nurse (LPN) had assumed the wound may have been self-inflicted and did not recognize the need to immediately report it to the facility or to the appropriate State agencies. 4. Review of facility abuse policy The abuse policy, reviewed on 03/20/17, noted a revision date of 07/16/13. The policy noted an injury of unknown origin as an injury which was not observed by any person or the source could not be explained by the patient; and the injury was suspicious because of the extent of the injury or the location of the injury. The policy indicated anyone who witnessed an incident of suspected abuse or neglect was to report the incident immediately to his/her supervisor and injuries of unknown origin would be investigated immediately to determine if abuse or neglect was suspected. b) Failure to ensure residents and/or family informed reporting abuse and/or neglect allegations 1. Resident #126 During an interview with Resident #126, on 03/22/17 at 10:31 a.m., the resident voiced concerns were reported to the facility staff. Upon inquiry, she said she did not know how to report to State agencies, and did not know the name of the ombudsman or how to contact her. 2. Resident #13 Resident #13, interviewed at 10:38 a.m. on 03/22/17 at 10:38 a.m., said she would refer concerns to the facility. Upon inquiry, the resident said she did not know how to report to State agencies, and did not know how to contact the ombudsman, or the purpose of an ombudsman. Both Resident #126 and Resident #13, during the interviews, denied knowledge of where to find contact information for State agencies in the facility. 3. An interview with Social Service coordinator (SSC) #60 on 03/22/17 at 12:28 p.m., the SSC said signs were posted and residents and/or families were notified of reporting requirements during the 72 hour meeting on admission. When asked how the information was disseminated to all residents and/or families the coordinator said a copy of resident rights was given to residents yearly. Upon inquiry, the coordinator looked at the form and said it did not contain State agency contact information. The SSC confirmed residents were only provided contact information during resident council meetings.",2020-09-01
950,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2017-03-22,241,E,0,1,SWUR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and medical record review, the facility failed to protect the dignity of a resident while receiving an enteral feeding and failed to address a second resident's odor and urinary incontinence. Observations occurred multiple times throughout the survey and represented a pattern of failed practice. Resident identifiers: #188 and #99. Facility census: 117. Findings include: a) Resident #188 On 03/21/17 at 8:35 a.m., Resident #188 was observed sitting in the hallway outside of her room with an enteral tube feeding infusing. The bottle of nutrition infusing was uncovered, exposing a label with the type of nutrition, the resident's name, the start date and the start time. Licensed Practical Nurse (LPN) #151 and Nurse Aide (NA) #172 were in the hall near Resident #188 upon discovery and were interviewed at that time. They were asked if enteral feeding bottles were usually left uncovered. NA #172 said, They are not, and then covered up the bottle with a cover that was already hanging on the pole with the enteral feeding bottle. LPN #151 agreed with NA #172. The Director of Nursing was interviewed, on 03/21/17 at 3:00 p.m., and she said the tube feeding bottles are not supposed to be uncovered. b) Resident #99 During the initial tour observation, on 03/12/17 between 5:00 p.m. and 6:00 p.m., an odor of urine was present at the doorway of Resident #99. A subsequent observation on 03/20/17 at 12:55 p.m., again revealed a strong odor of urine. A follow-up observation at 2:54 p.m., with Licensed Practical Nurse (LPN) #55, confirmed the odor of urine was present, but no evidence of incontinence was visible. During a random observation, on 03/21/17 at 9:16 p.m., a strong odor of urine/ammonia was present into the hallway. Resident #99's bed was visible from the doorway and the covers were pulled up from the side of the bed. The fitted sheet appeared wet with a brown border along the edge. While observing, family members exited the facility via the hallway. Multiple staff members walked past the door and did not enter to provide care. The staff passed ice, entered in and out of other resident's rooms, and stopped to converse with the nurse. Upon inquiry, at 10:03 p.m., LPN #17 confirmed a strong odor of urine into the hallway, and Resident #99's sheet discolored with a wet appearance outlined with a brown border. Nurse Aide (NA) #114 asked Resident #99 if she wanted to take a shower and the resident said yes. Without explaining, the NA removed the resident's covers and pulled her legs toward the side of the bed. The resident changed her mind, tried to pull the covers back over her and when NA #114 attempted to intervene, Resident #99 struck at her. The medical record, reviewed on 03/21/17, noted a care plan which indicated Resident #99 required assistance with bathing, hygiene, bed mobility, transfers, ambulation due to a [DIAGNOSES REDACTED]. The minimum data set (MDS) with an assessment reference date of 01/02/17 noted the brief interview for mental status (BIMS) was not completed due to the resident was rarely understood. NA #165, interviewed at 10:51 p.m. voiced Resident #99's incontinence cycle had not been figured out. The NA said Resident #99 had been a health care professional, and would hide her soiled brief, as though she might be embarrassed. She voiced the resident would usually allow staff to assist her if she trusted them and they were patient with her. During a discussion with the center nurse executive (CNE) at 11:45 p.m., she said staff should have checked the resident at least every two (2) hours and should not have left her wet for 45 minutes before offering to change her. The CNE acknowledged the lingering strong odor of urine and failure to provide care in a timely manner did not promote the resident's dignity. .",2020-09-01
951,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2017-03-22,253,E,0,1,SWUR11,"Based on observations and staff interview, the facility failed to provide maintenance and housekeeping services necessary to maintain a comfortable and sanitary interior for eleven (11) of thirty-five (35) rooms observed during Stage 1 of the Quality Indicator Survey (QIS). The entrance and the bathroom doors had scratches and/or gouges. The bottom of the bathroom wall was cracked near the toilet. There was a discolored substance on caulking of the toilet and there was brown stains inside the toilets. The heating cooling system had dust between the vents. There were deep scratches on the night stands, wardrobes. Tape marks was on the bathroom doors. The bathroom call light cord had brown stains on the cord. This had the potential to affect more than an isolated number of residents. Room identifiers: 107, 112, 114, 115, 120, 123, 124, 136, 154, 156, and 157. Facility census 117. Findings Include: a) Cosmetic imperfection Observations made with the Maintenance Supervisor #62 on 03/21/17 beginning at 11:20 a.m., found the following cosmetic imperfections: --Room 107 had brown stains on the back of the toilet bowl, scratches on the wardrobe door, and there was deep scratches in the bathroom door. --Room 112 had dust between the vents of the heating cooling system. --Room 114 had scratches on the bathroom door. --Room 115 had brown stains in the toilet bowl, and dust between the vents of the heating cooling system. --Room 120 had a night stand with scrapes on the front edge, and scrapes on the lower inner bathroom room door. --Room 123 had large scrapes on the bathroom door, and a hole on the inside of the door. --Room 124 had a crack in the bathroom floor against the wall beneath the toilet paper holder. --Room 136 had tape all over the door and brown stains on the toilet. --Room 154 had brown stains on the call light cord. --Room 156 had tape on the bathroom door. --Room 157 had tape on the bathroom door. b) Observation and interview with the maintenance supervisor (MS) During the observation of the physical environment with the Maintenance Supervisor #62 on 03/21/17 beginning at 11:20 a.m., he verified the observed cosmetic imperfections all needed to be repaired.",2020-09-01
952,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2017-03-22,258,D,0,1,SWUR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, the facility failed to maintain comfortable sound levels for one (1) of two (2) residents reviewed for comfortable sound levels. A comfortable sound level was not maintained in the south back hall of the facility. Resident identifier: #60. Facility census: 117. Findings include: a) Resident #60 In an interview with Resident #60, on 03/21/17 at 10:30 p.m., he said the resident across the hall leaves her television (TV) on loud, and no one can get any sleep. room [ROOM NUMBER]'s television could be heard at high volume in Resident #60's room during the time of this interview. b) Observation of the loud television coming from Resident #60's room Observation of the hall way of Rooms 116 - 131 on the south back hall found the TV in room in Resident #60's room could be heard very at high volume out in the hall way from 9:00 p.m. - 11:10 p.m. on 03/21/17. c) Interview with unit manager-registered nurse (UM-RN) #57 Interview at the entrance of Resident #60's room with UM-RN #57 took place at 11:12 p.m. on 03/21/17. The UM-RN was asked whether the resident television was too loud, she acknowledged the television was turned up too loud and the resident TV needed to be turned down so not to bother other residents. The UM-RN entered the room, and she asked the resident if she could turn the TV down, and the resident allowed the nurse to turn her TV down. The nurse said Resident #60 needed to have head phones so her TV does not bother other residents at the facility.",2020-09-01